404 not found j aziz fatm med den college july december 2020; vol. 2, no. 2 36 importance of teaching medical ethics at undergraduate level in medical colleges dr. farah amir ali advancement of science and technology including storm of social media, has developed many challenges for healthcare providers more than ever. in every day practice medical professionals face many situations where decisions are not merely taken on clinical and technical grounds but also require sound knowledge of ethics. in order to justify individual actions in particular situation, the code of conduct is always there. the importance of understanding medical ethics is undeniable due to increasing litigations and complexities in medical practice. on the other hand, majority of population is depending on doctors who are not adequately trained for medical ethics and professionalism. medical ethics has become core part of medical education in worldwide but in our scenario, it seems to be left alone on personal opinions and routine practices. our current undergraduate medical curriculum is still deficient in providing proper frame work to cover medical ethics. few reasons that we still lack well defined curriculum are shortage of time, lack of qualified experts and deficiency of realizing its importance in providing quality care to patients. due to which it has been found that graduates face problem in dealing with situations of medico-legal and ethics.1medical ethics has been defined as “the analytical activity in which the concepts, assumptions, beliefs, attitudes, emotions, reasons, and arguments underlying medico-moral decision making are examined critically.”2 it covers practicing as well as research ethics. the six common values that apply to medical ethics are autonomy, beneficence, nonmaleficence (first do not harm), justice, dignity, truthful, and honesty3. these mentioned norms themselves are not sufficient to deal with a particular situation. medical ethics is well defined curriculum which includes core topics ranges from informed consent to refusal of treatment, rights, confidentiality, good practices and vulnerabilities created by doctors and students etc. although it is obligatory to health care provider that adequate information is given to patients for treatment and procedure. they are also aware of potential benefits and risks of the given treatment.4 currently the curriculum which is taught in our medical colleges is aligned according to the prescribed text correspondence: dr. farah amir ali email: farah.zulfiqar@yahoo.com books of west, which often does not meet the need of our community. as knowledge is expanding so rapidly, there is necessity that we in pakistan revise our curriculum according to local context and omit unnecessary cramming components and replace it with more practical approaches which help in developing community doctor, who can rationally treat patient. ethics and professionalism should be included as the core part of syllabus in spiral manner so that our medical graduates are skilled enough to manage risky situations and have good communication and inter personal skills. there are multiple justifications that we should consider teaching ethics at undergraduate level. it would be helpful in resolving disputes among doctors, patients and relatives. it would give insight to make decisions beyond personal values and emotions on ethical codes. on the other hand, it is equally important to maintain fair relationship with other clinicians. it provides means of creating virtuous and skillful doctors for evaluating and resolving ethical dilemmas. teaching ethics may deal to reduce cynicism in medical students and also help to abate ethical erosion as they progress in their careers. in developed countries like canada, usa, uk, this course is integral part of their curriculum and it is evident from several researches that teaching ethics at undergraduate, has positive impact. it increases the decision-making abilities and contribute in daily working of medical professionals. we cannot teach their ethics as our religious and cultural context is entirely different from western world. so, we need to develop medical ethics curriculum along with its compulsory examination to assess the ability of students to critically and logically make decisions on ethical issues. it is the demand of time that we work altogether to train “community friendly ethical health care provider” to improve our healthcare system. conflict of interest: none references: 1. ahsin s, shahid a, gondal ghm. teaching communication skills and medical ethics to undergraduate. j. adv med & prof. 2013;1(3):72-76. 2. pasha hc, ali m. principles of islamic medical ethics jbima. 2019;1 (1). https://jbima. com/article / principles-of-islamic-medical-ethics. [cited on:august 23,2020] 3. beauchamp tl, childress jf. principles of biomedical ethics. 5th ed. oxford university press; 2001.454. isbn 0-19-514332-9 https://jme.bmj.com/content/28/5/332.2.[cited on: august223,2020] editorial https://jbima.com/author/jbima_author/ https://jme.bmj.com/content/28/5/332.2.%5bcited j aziz fatm med den college july december 2020; vol. 2, no. 2 37 4. health ethics in practice: key issues and challenges. global health ethics key issues global network of who collaborating centers for bioethics world health organization. 2015 farah amir ali j aziz fatm med den college january – june 2022; vol. 4, no.1 42 case report compound type-dual blood supply to gallbladder revealed during laparoscopic cholecystectomy abdul majeed, mohammad kamran ch, mohammad zakir, tayyab abbas summary during the laparoscopic cholecystectomy, a rare variation was found in a female patient. there was a large vessel exiting from liver parenchyma to gall bladder directly. it was pulsating; so was an unusual artery. the cystic artery was present properly at its usual anatomical site in callot's triangle. the knowledge of these vascular variations is very significant in surgical interventions involving the biliary tree. it is of key importance for laparoscopic surgeons to know like this vascular variation to avoid catastrophic bleeding. the report emphasizes the vascular variation and the anomalous vessel to accomplish safe and uneventful hepatobiliary surgeries. keywords: callot's triangle, cholecystectomy, gall bladder case report a 32 years female patient presented to our surgical out-patient department on 22 june 2021 with pain in right hypochondrium on and off. ultrasound findings were of chronic cholecystitis due to cholelithiasis. she was admitted in surgical unit #1 jinnah hospital lahorepakistan. she was operated upon for the cholecystectomy laparoscopically. during laparoscopic cholecystectomy, dual arterial supply to gall bladder was noted.3 presence of this variation is of utmost importance for surgeon to avoid unexpected bleeding during surgery.1,2 the cystic artery was present properly at its usual anatomical site in callot's triangle. in addition to this, unusual large artery about 2.5 times the diameter of cystic artery was found about 3 cm above the callot's triangle that was pulsating. dr. abdul majeed mbbs, fcps senior registrar jinnah hospital, lhr dr. mohammad kamran ch mbbs, fcps associate professor jinnah hospital, lhr dr. mohammad zakir mbbs, fcps professor jinnah hospital, lhr dr. tayyab abbas mbbs, fcps professor jinnah hospital, lhr correspondence: abdul majeed email: majeed066@yahoo.com it was arising from liver parenchyma and running transversely to enter the gall bladder wall directly. just after entering the gall bladder, it divided into two branches: one large inferior and other small superior. as it was pulsating; so, there was no doubt for it to be an artery. it was hooked carefully and was clipped with lt-200. then it was divided with l-hook through cauterization. previous researches also reported presence of abberent vasculature in gallbladder along with the cystic artery (proper) present within the callot’s triangle.3,4 the gall bladder had compound dual arterial supply. otherwise, cholecystectomy was performed safe and sound laparoscopically. fig:1 dual artery supply to gallbladder j aziz fatm med den college january – june 2022; vol. 4, no.1 43 fig:2 accessory cystic artery clipped with lt300 discussion usually, gall bladder has the single blood supply from the right hepatic arteryas a cystic artery. but in some individuals, it may have dual blood supply or blood supply from an aberrant artery.5 the conversion of laparoscopic surgery to open cholecystectomy can be reduced if the surgeon has prior awareness of these anatomical variations; thus reducing the complications.6 infact, during embryonic life, the gall bladder has many blood vessels directly arising from liver into the gall bladder. but at the end of maturation, all the aberrant blood vessels regress. sometimes, one such vessels persist as the aberrant vessels at the sphere of the norm.7a rare variation was also seen by dolensek j where an accessory left hepatic artery and accessory right hepatic artery from which double cystic artery arose (one of which was low lying).8 my presented case is like this one. during laparoscopic cholecystectomy, an aberrant (large) artery was seen pulsating; that was coming directly from liver parenchyma and entering the gall bladder mid body. it was about 2.5 times thicker than the cystic artery (proper) as the picture shows. surgical significance: it was an unusual vessel that driven me to report it as a case. it was of utmost surgical importance as even a small rash handling to this vessel could cause the uncontrollable bleeding.2 but it was clipped and divided safely. a surgeon should have the clean and clear concept of these vascular variations. 3 conclusion during laparoscopic as well as open procedures operated upon the biliary tract, sudden anatomical variations (especially of vessels) can be a cause of concern for surgeons. a sound knowledge of such variations is essential to prevent the iatrogenic traumas in these regions of hepatobiliary triangle. conflict of interest: none references 1. jansirani d, mugunthan n, phalgunan v. caterpillar hump of right hepatic artery: incidence and surgical significance. national journal of clinical anatomy. 2012 ;1(3):121-24 2. aristotle s. variations in origin and course of cystic artery and its relations to calot’s triangle with its clinical implications. oa anatomy. 2014 ;2(2):2-17. 3. na michels, blood supply and anatomy of the upper abdominal organs with descriptive atlas. philadelphia: lippincot company 1955: 155-175 4. b kk.dual cystic arteries in association with caterpillar hump of right hepatic arterya case report and its surgical relevance.j clin of diagn res.2015; 9(7):ad01-ad02 5. al-sayigh ha. the incidence of cystic artery variation during laproscopic surgery. medical journal of babylon 20107:389403 6. ayyaz m, fatima t, ahmed g. arterial anatomy in calot’s triangle as viewed through the laparoscope. annals of king edward medical university. 2001;7(3);183-185 7. nagral s. anatomy relevant to cholecystectomy. minim access surg. 2005 ;1(2):53-58. doi: 10.4103/0972-9941.16527. 8. dolensek j.triple arterial blood supply to liver and double cystic arteries. folia morphol (warsz). 2017;76(3):523-526. doi: 10.5603/fm.a2017.0008. author contribution all author contributed to this case report are responsible for material provided. abdul majeed et al date of submission: 10-0920201 revised received: 21-112021 accepted: 23-11-2021 j aziz fatm med den college july december 2021; vol. 3, no. 2 65 case report a case report: amelogenesis imperfecta rabia zia, samreen aqeel summary the aim of this case report is to come up with patient friendly restorative treatment for a young female patient with severe ai using indirect composite veneers for anteriors and metal crowns on posteriors. amelogenesis imperfecta is defined as genetic determined malformation with various manifestations particularly concerning functional disability and enamel discoloration. after the performed dental procedure, patient improved a lot in terms of chewing efficacy, which in turn enhance her quality of life. her confidence level was also boosted up with acceptable esthetics. the patient was better able to maintain her oral hygiene in terms of plaque removal and tooth brushing. clinical relevance: patients with amelogenesis imperfect needs life time follow up with high level of maintenance provided with the prosthesis. this particular management provided the patient with least invasive procedure in terms of simplicity and cost effectiveness. the current case report exhibits that restorative treatment enhances the quality of life of patients. some other aspects needs to be addressed depending upon the severity and affordability of patients, such as surgical correction of the jaws, and orthodontic treatment. keywords: amelogenesis imperfect, clinical management, indirect restorations, follow-up, restorative treatment introduction amelogenesis imperfecta (ai) is a hereditary derived enamel development disorder of enamel formation formed by ameloblasts that effects quality and quantity of tooth enamel. this usually affects permanent and deciduous dentitions. 1 the diagnoses of ai is confirmed through various tests including, clinical examination, radiographic analysis and gene analysis. on clinical examination ai picture is presented as reduced enamel thickness or as with mottled enamel appearance or with brownish to greyish enamel discoloration. on the radiograph no enamel structure is seen on teeth or much reduced enamel structure is present 3. this mutation can even pass from parents to children. it can even affect subjects with no family history. previous literature showed that not a single gene alteration is responsible for this condition rather than multiple genes are responsible for causing this state. a study carried out dr. rabia zia, bds pgr operative dentistry fatima memorial hospital lhr dr. samreen aqeel, bds pgr operative dentistry fatima memorial hospital lhr correspondence: rabia zia email: rabiya719@gmail.com on turkish families subjects who had hypomaturation amelogenesis imperfecta showing whole-exome sequence analyses identified disease that causes mutations in each proband, and these mutations cosegregated with the amelogenesis imperfecta phenotype in all recruited members of each family. gene analysis showed amelx missense mutation that is responsible for increased exonic definition of exon 4 and the mmp20 mutation declines exonic definition of exon one. subsequently these gene alterations elicits an alteration of exon usage during rna splicing, causing the enamel malformations.2 it is found that depending on the study population ai prevalence ranged from 1:700 to 1:14,000. the extracted data from the previous researches shows, the condition has some genetic patterns, such as autosomal dominant, recessive and rarely as x chromosome-linked inheritance. on the other hand, many researches shows that ai occurs when there is mutation in the genes.3 it depends upon the gene involved and at what time the mutation occurs, various alterations have been noted in enamel from superficial discoloration to complete absence of enamel formation. according to phenotypic alteration, amelogenesis imperfecta can be classified as type i hypoplastic, type ii hypomatured, type iii hypocalcified, and type iv hypomatured-hypoplastic. another classification is also available which depends upon not only on the mailto:rabiya719@gmail.com j aziz fatm med den college july december 2021; vol. 3, no. 2 66 enamel appearance but also the genetic components which divides the ai into 15 subtypes. these fifteen aforementioned subtypes are the most widely accepted classification so far. though ai is mainly an enamel related tooth disorder, however, along with this major presentation, other features such as congenital missing teeth, pulp calcifications delayed tooth eruption, root resorption, open bite, negative overjet, and altered vertical jaw relationship were also seen in such patients.4 depending upon the varied clinical presentation, role of different disciplines of dentistry is required for the successful treatment of ai subjects that includes a prosthodontist, a restorative dentist, a maxillofacial surgeon and pediatric dentist.4 it is observed that as amelogenesis imperfecta patients presents at younger age hence treatment options usually starts with restorative procedures. so it is recommended to start with minimally invasive procedures i.e direct composite fillings. however literature shows that as the enamel quality of ai patients are compromised therefore direct composite fillings have higher failure rate.5 the aim of this case report is to come up with patient friendly restorative treatment for a young female patient with severe ai using indirect composite veneers for anterior and metal crowns on posteriors. case report amelogenesis imperfecta is an enamel formation disorder, diagnosed on the basis of clinical and radiographical findings and gene analysis. a 23 year old adult female patient reported in the opd of fatima memorial hospital on september 2018 with the complaint of sensitivity and poor aesthetics. she was presented with discoloration of the teeth and open bite with poor aesthetics and sensitive teeth. treatment was started after taking permission from supervisor and principal of the institute. after the approval a detailed history was recorded about consanguinity and family history of the same problem was recorded to rule out genetic predisposition. her area of residency was inquired to rule out the high fluoride level. patient was asked for the gene analysis but she refused because of un affordability, thorough extra oral and intra oral examination revealed the presence of un healthy direct composite fillings on facial surfaces of upper and lower anterior teeth with poor oral hygiene and periodontal condition. as affected subjects of ai are reluctant to smile, speak and socialize themselves because of their overall appearance of face which eventually affects their physiological wellbeing, as they are constantly humiliated by their friends and relatives, so this case highlights the importance of timely and accurate management of amelogenesis imperfecta. the treatment of amelogenesis imperfecta is very costly so the affected patients be should facilitated at government level which bears high investment on oral aesthetics. radiographic findings: figure no.1 is showing orthopantomogram (opg) on which it was found that tooth #46 #47 (federation dentire international classification of teeth) were grossly carious and were not in a condition to be saved anymore as their furcation were involved with minimal coronal tooth structure left ,as shown in fig 2. hence, she was figure 1: orthopantomogram sent to minor oral surgery department for extractions. it was noticed that upper left c was retained, whereas, upper left canine was impacted in the bone. in fig 3 the upper right quadrant #15 #16 were found carious with pulpal involvement so their root canal treatment (rct’s) were planned. in fig 4 upper left quadrant #27 and in fig 5 #26 were found grossly carious with pulpal involvement and so their rct’s were planned and executed followed by metal crowns as shown in fig 10 and fig 12. figures; periapical pre-treatment x-rays a case report: amelogenesis imperfecta j aziz fatm med den college july december 2021; vol. 3, no. 2 67 treatment adopted according to the clinical picture of patient, her ideal treatment plan would have started with orthodontics to align and correct the bite of upper and lower anterior teeth fully and canine impaction on upper left quadrant prior to any other treatment, but patient had major concerns over a lengthy treatment plan. so our first phase of treatment started with a smile analysis, followed by a full set of photographs, alginate impressions, cast articulation and diagnostic mock up. veneer‘s preparation: patient’s main concern was esthetics. so after smile analysis it was decided to place indirect composite veneers on upper from #14 to #24 and lower anteriors from #34 to #44 as shown in fig 7. metal crowns after root canal treatments were given. veneer preparation was done with tapering fissure bur. first the existing composite restorations were removed then 0.75mm cutting was done. after shade selection putty impression was taken and sent to lab for indirect composite veneers. veneers were cemented with relyx cement as shown in fig 8. restorative work: class 2 amalgam fillings were performed on proximal adjacent sides as can be seen in on fig 10 and fig 13 on #17 and#25. rcts were performed on #15 #16 #26 #27 #36 and #37 followed by applying the subject with metal crowns. metal crowns after root canal treatments were given. patient was referred to prosthodontics department for 2 unit removable partial denture. there her impressions and bite was recorded and sent to the laboratory for manufacturing of partial dentures. after that its trial was done and wax up was sent to lab for final curing. denture was received after final polishing from the lab and was given to the patient with instructions for its maintenance. it was applied after extractions spaces were healed as shown in fig 14. after all the hard work and patients good compliance results made both the patient and her dentist satisfied. discussion study done by parekh et al stated that 77% of the patients with ai mentioned reported with discoloration and increased sensitivity as a main fig 7 fig 8 fig 9 fig 10 fig 11 fig 12 fig 13 fig 14 rabia zia et al j aziz fatm med den college july december 2021; vol. 3, no. 2 68 compliant7and this also goes in accordance with the current study presentation. it has been found the main cause of lack of enamel, distorted tooth shape and smaller appearance is exposed dentin, which might be the reason explaining over sensitivity of the dysplastic teeth.8 this is also the finding which corresponds to our presentation. numerious treatment options can be opted for the features and characteristics of ai have been reported. to accomplish acceptable results, multidisciplinary approach is required for the proper execution of treatment plan. in another study 24% to 64% of patients affected by ai presented with anterior open bite and mal-occlusions which is in line with our study. acknowledgment: i highly acknowledge supervisor prof. dr. saroosh ehsan and assistant professor dr. shaila tahir for their unconditional support and guidance. conflict of interest: none references 1. witkop cj., jr amelogenesis imperfecta, dentinogenesis imperfecta and dentin dysplasia revisited: problems in classification. j oralpathol. 1988;17:547553.doi: 10.1111/j.16000714.1988.tb01332.x.) 2. kim yj, kang j, seymen f, koruyucu m, zhang h, kasimoglu y, bayram m, tuna-ince eb, bayrak s, tuloglu n, hu jc, simmer jp, kim jw. alteration of exon definition causes amelogenesis imperfecta. j dent res. 2020 apr;99(4):410-418. doi: 10.1177/0022034520901708. 3. d ceyhan, z kirzioglu, t emek .a long-term clinical study on individuals with amelogenesis imperfecta. niger j clinpract.2021;22(8):11571162.doi:10.4103/njcp.njcp2_72_18) 4. novelli c, pascadopoli m, scribante a..restorative treatment of amelogenesis imperfecta with prefabricated composite veneers. caserepdent.2021;2021:3192882.doi:10.1155/2021/3192882.ec ollection2021 5. b. c. yaman, f. ozer, c. s. cabukusta, m. m. eren, f. koray, and m. b. blatz, “microtensile bond strength to enamel affected by hypoplastic amelogenesis imperfecta,” the journal of adhesive dentistry.2014;16(1);7–14. 6. sönmez iş, aras ş, tunç eş, küçükeşmen ç. clinical success of deproteinization in hypocalcified amelogenesis imperfecta. quintessence international. 2009;40(2). 7. parekh s, almehateb m, cunningham sj. how do children with amelogenesis imperfecta feel about their teeth? int j paediatr dent. 2014;24:326–335. doi: 10.1111/ipd.12080. 8. sabandal mmi, dammaschke t, schäfer e. restorative treatment in a case of amelogenesis imperfecta and 9-year follow-up: a case report.head face med. 2020 nov 19;16(1):28. doi: 10.1186/s13005-020-00243 9. koruyucu m, bayram m, tuna eb, gencay k, seymen f. clinical findings and long-term managements of patients with amelogenesisimperfecta. eurjdent. 2014;8:546552.doi: 10.4103 1305-7456.143640. 10. sabandal mm , dammaschke t, schäfer e. restorative treatment in a case of amelogenesis imperfecta and 9-year follow-up: a case report. head face med. 2020; 16: (28). doi: 10.1186/s13005-020-00243-1 author contribution all authors contributed equally and are responsible for material provided. received: 11 apr 20201, revised received: 20 aug 2021, accepted: 30 sep 2021 a case report: amelogenesis imperfecta https://pubmed.ncbi.nlm.nih.gov/31999931/ https://pubmed.ncbi.nlm.nih.gov/31999931/ https://pubmed.ncbi.nlm.nih.gov/34394996/ https://pubmed.ncbi.nlm.nih.gov/34394996/ https://pubmed.ncbi.nlm.nih.gov/33208174/ https://pubmed.ncbi.nlm.nih.gov/33208174/ https://pubmed.ncbi.nlm.nih.gov/33208174/ https://www.ncbi.nlm.nih.gov/pubmed/?term=dammaschke%20t%5bauthor%5d&cauthor=true&cauthor_uid=33208174 https://www.ncbi.nlm.nih.gov/pubmed/?term=sch%26%23x000e4%3bfer%20e%5bauthor%5d&cauthor=true&cauthor_uid=33208174 https://www.ncbi.nlm.nih.gov/pmc/articles/pmc7677852/ https://dx.doi.org/10.1186%2fs13005-020-00243-1 j aziz fatm med den college january june 2021; vol. 3, no. 1 17 original article tobacco smoking is a risk factor for decline peak expiratory flow rate in young healthy smokers saifullah shaikh, rabiya ali, hina moazzam abstract objective: to compare peak expiratory flow rate among smokers and nonsmokers and to establish a relation between pefr and smoking. methodology: a cross-sectional study was conducted at bahria medical and dental college, karachi from august to october 2020. it was comprised of 151 male smokers and nonsmokers healthy subjects of 20 to 25 years age. after taking ethical approval (erc 21/2020), hundred and fifty one subjects, who fulfill the inclusion criteria were enrolled in the study. pefr values were estimated by wright’s peak flow meter. data was analyzed by spss22. mean pefr was compared among smokers and nonsmokers. association between pefr and smoking was determined by regression analysis. p-value ≤0.05 was considered significant. results: this study was comprised of 151 male participants. of total subjects, 49 (32.5%), 102(67.5%) were smokers and nonsmokers respectively. mean±sd age of the study participant’s was 22.74±2.657 years. smokers have lower pefr values as compared to nonsmokers (323.94 versus 352.65l/min.), this difference was statistically significant (p-value 0.04). regression analysis showed the negative association of pefr with smoking, however, this association was not statistically significant (p-value 0.17). conclusion: peak expiratory rate was comparatively lower in smokers than nonsmokers healthy young subjects. keywords: healthy subject, peak expiratory flow rate, smokers, nonsmokers, wright’s peak flow meter. introduction the trend of tobacco consumption is increasing at an alarming rate among young adults across the world.1 the highest rate of tobacco smoking were reported in south asian countries.1 in pakistan, tobacco is consumed in various forms such as pipes, cigarettes, hookah/shisha, cigar, pan and gutka. however the most common source of tobacco consumption is in the form of cigarette smoking.2 the peer pressure, parental smoking and poor compliance to bans on promotion of tobacco are contributing factors for promoting of smoking especially in young adults.3 there are several thousand chemical substances including nicotine, nitrites, hydrogen cyanide, ammonia, arsenic, carbon mono oxide, and several others substances responsible for effecting oxygen transport by the erythrocytes. dr. saifullah shaikh mbbs, mphil assistant professor bahria university medical and dental college, khi dr. rabiya ali,mbbs, mphil. assistant professor karachi institute of medical sciences (kims), cmh, khi dr hina moazzam mbbs, mphil. assistant professor bahria university medical and dental college khi correspondence: rabiya ali email: rabiya.rehan@gmail.com thence, ultimately damaging every system of the body. tobacco consumption is the second leading cause of preventable death worldwide and accountable for six million annual deaths across the world.3 according to estimates by the tobacco control cell ministry of national health services regulation and coordination, government of pakistan, approx. 160,100 mortalities every year are due to tobacco smoke.4 tobacco smoking primarily damages the respiratory system causing airflow limitation and subsequent chronic obstructive pulmonary diseases (copd). it is characterized as the limitation of airflow which is considered as the irreversible state. this limitation is believed due to the development of inflammation or thickened respiratory wall resulting from smoking.5 countries where tobacco consumption is higher are at risk of increasing burden of irreversible chronic obstructive pulmonary disease. due to asymptomatic nature of the early stages of copd, it usually remains undiagnosed especially in developing countries with limited resources.6 subjects with misdiagnosis might be prone to the exacerbation such as pneumonia, pneumothorax, associated with the decline in lung functions leading to unexpected early death particularly in smokers. airflow limitation before progression to copd can be reversed by smoking cessation, so by early detection and treatment, burden of this chronic mailto:rabiya.rehan@gmail.com j aziz fatm med den college january june 2021; vol. 3, no. 1 18 disease might be reduced.7 forced expiratory volume in 1st second (fev1) and forced vital capacity (fvc) are gold standard spirometric parameters for assessment of lung functions and diagnosis of symptomatic chronic obstructive pulmonary disease (copd). however, these parameters are not reliable for the detection of asymptomatic airflow obstruction. on contrary to this, peak expiratory flow rate is the simple, reliable, and convenient procedure to detect asymptomatic cases as well as obstruction of smaller airways.8,9 global initiative for chronic obstructive lung disease (gold) encourages the early detection of airflow obstruction in asymptomatic cases by reliable new tools to reduce the burden of irreversible airway obstruction.8 data concerning the assessment of lung functions by pefr in healthy young adults is still limited in pakistan. this study was designed to assess lung functions of the healthy young smokers and nonsmokers by using peak expiratory flow rate. methodology this cross-sectional study was conducted at bahria medical and dental college, karachi from august to october 2020. it was comprised of 151 male subjects 20 to 25 years ago. after taking ethical approval from the institute (erc21/2020), participants were selected from 1st year to final year mbbs by nonprobability convenience sampling technique. initially, 200 students were interviewed and relevant information about ethnicity, residence, and socioeconomic status, history of cigarettes smoking including duration and pack-years (number of cigarettes per day by years), history of prolonged cough, phlegm, allergies, copd and frequent respiratory infections were tailored on the predesigned proforma. medical history about use of bronchodilators for airway obstruction was also recorded. hundred and fifty one students who fulfilled the inclusion criteria were included in the study. healthy male cigarette smokers of age 2025 years, who reported smoking more than 100 cigarettes in their life regularly and had neither previous history of airway obstruction were recruited in the study. for the comparison purpose, nonsmokers, who never smoke or smoke less than 100 cigarettes in their life and don’t have a previous history of airway obstruction of the same age were included in the study. female students prevent gender bias, students with a history of asthma, copd, pneumonia tuberculosis, lung cancers, and any systemic disease affecting lung functions were excluded. students having thoracic spine deformities and oral lesions, who were unable to perform the procedure were excluded. the purpose, benefits, and risk of the study as well as procedure were explained and participants who gave consent were included in the study. confidentiality was assured to all subjects. anthropometric measurements were recorded by standard protocol. weight in kilogram (kg) and height in centimeters (cm) were obtained by stadiometer. bmi was estimated by weight in kg/height in m2. clinical examination was done to exclude any systemic disorder affecting the respiratory system. pefr was recorded by wright’s peak flow meter following standard guidelines by the american thoracic society (ats). the students were directed to take a deep breath and exhale with forced expiration as fast as possible in a single blow into the apparatus while maintaining an airtight seal between lip and mouthpiece. three consecutive readings were recorded at about twominutes intervals, and the highest value was recorded for data analysis. pefr values among the smokers and nonsmokers were compared. results the current study comprised of 151 male participants. of the total subject 102(67.5%) were smokers and 49 (32.5) were nonsmokers. mean±sd age of the study participants was 22.74±2.657 years. the descriptive of the study population are described in table1. table1: basic characteristics of study population(n=151) study variables mean± sd age (years) 22.74±2.657 weight (kilogram) 78.12±12.79 height (centimeter) 170.07±12.05 bmi (kilogram/meter2) 38.19±4.72 pefr (liter/minute) 343.33±75.32 table 2 depicts the comparison of mean pefr among smokers and nonsmokers. smokers have lower pefr values as compared to nonsmokers; this difference was statistically significant with a p-value of 0.04.(table 2). table 2: comparison of pefr among smokers and non smokers(n=151) study groups frequency n(%) pefr(l/min) mean±sd p-value smokers 102(67.5) 323.94±77.60 0.045* non smokers 49(32.5) 352.65±89.26 peak expiratory flow rate (pefr), liter/minute (l/min), p-value ≤0.05 was taken significantly saifullah shaikh et al. j aziz fatm med den college january june 2021; vol. 3, no. 1 19 regression analysis showed the negative association of pefr with smoking with beta coefficient β value -7.89. however, this association was not found to be statistically significant (p-value 0.17). discussion the increasing trend of tobacco smoking especially the youth affecting lung functions is a serious issue in this modern era. pefr is a simple and reliable measure of airflow in the bronchial tree and it gives an idea about bronchial tone. evidence is available showing pefr is adversely affected by smoking. initial stages of airflow obstruction due to tobacco smoking are reversible but it can progress to irrepressible obstructive pulmonary disease if not managed timely. even symptom free smokers also have diminished values of pefr than nonsmokers reflecting its deleterious effects of smoking on lung functions.9 this study is conducted to highlight this burning issue and focused to establish the relation between smoking and pefr. almost one-third of our study population were smokers (32.5%). the mean pefr of the total population was 343.33 l/min. similar reference values have been reported by an indian study by jena et al.10 on comparing the pefr among the smokers and nonsmokers, we found a significant reduction in pefr value in smokers as compared to nonsmokers. our results were congruent with previous local research showing a significant decline in pefr in smokers than non-smokers.11 these results are also in agreement with other international studies, reporting reduced pefr values in smokers.12,13 repeated inflammation is frequent and constant pathological finding in cigarette smokers destroying alveolar walls, which might be the possible reason for the reduction in pefr. increase secretion of inflammatory mediators causing hyper-reactivity are the hallmarks of tobacco consumption that enhances the tone of alveolar smooth muscles. 12 alveolar wall thickness and narrowing due to bronchopulmonary leakage and edema eventually causes decreased diffusing capacity and further aggravate airway obstruction leading to a reduction in pefr.13-15 the current study showed a negative association of pefr with smoking, β coefficient of −7.89 suggested that each unit increase in smoking rate will lead to a 7.89 unit decrease in pefr. however, this association was not found to be statistically significant which might be due to the small sample size. our results are justified by indian researches conducted in india showing a strong negative correlation of smoking with pefr.16 early stages of airway obstruction can be reverted to normal with normal lung functions, if cigarette smoking cessation is implanted as early as possible. awareness and motivational programs should be conducted at the government level for healthy youth to discourage smoking. limitations: it was a cross-sectional study, causal inferences were not established. small sample size may not represent the whole population. conclusion peak expiratory flow rate was comparatively lower in smokers than nonsmokers healthy young subjects. funding source: none. conflicts of interest: none. references 1. who global report on trends in the prevalence of tobacco use.2000-2025, third edition geneva: world health organization;2019.availableat:file:///c:/users/hp/downloads /9789240000032eng.pdf [ cited on: dec 2,2020] 2. saqib man, rafique i, qureshi h, munir ma, bashir r, babur wasim arif, bw et al. burden of tobacco in pakistan: findings from global adult tobacco survey 2014.nicotine & tobacco research. 2018;20(9): 1138– 143, https://doi.org/10.1093/ntr/ntx179. 3. khanal gn, khatri rb burden, prevention and control of tobacco consumption in nepal: a narrative review of existing evidence.inthealth.2021;13(2):110121.doi:10.1093/inthealth/ ihaa055. 4. significant initiatives/achievements of tobacco control cell. available from :http://www.tcc.gov.pk/achievments.php. [cited on: dec4,2020]. 5. harita p vyas, rutvee p vinchhi, megha s sheth, neeta j vyas. comparison of pulmonary function among smokers and nonsmokers– a retrospective studyint j med sci public health.2014;3(10):12321234.doi: 10.5455/ijmsph.2014.0907 20144 6. çolak y, afzal s, nordestgaard bg, vestbo j, lange p prognosis of asymptomatic and symptomatic, undiagnosed copd in the general population in denmark: a prospective cohort study.lancet respir med. 2017; 5(5):426-434. doi: 10. 1016/s2213-2600(17)30119-4. 7. almagro p, soriano jb. underdiagnosis in copd: a battle worth fighting. the lancet respiratory medicine. 2017; 5 (5):367-8. 8. global initiative for chronic obstructive lung disease (gold). global strategy for the diagnosis, management, and prevention of chronic obstructive lung diseases(gold). 2018report.https://goldcopd.org/wp-content/uploads /2017 /11 /gold-2018-v6.0-final-revised-20-nov_wms.pdf [cited on dec4,2020] 9. nighute s,buge k, kumar s. effect of cigarette smoking on peak expiratory flow rate: a short review. international journal of current research in physiology and pharmacology (ijcrpp). 2017 dec 10;1(1):3-5. tobacco smoking & pefr file:///c:/users/hp/downloads/9789240000032eng.pdf file:///c:/users/hp/downloads/9789240000032eng.pdf javascript:; javascript:; javascript:; javascript:; javascript:; javascript:; javascript:; javascript:; javascript:; https://doi.org/10.1093/ntr/ntx179 https://pubmed.ncbi.nlm.nih.gov/32914846/ https://pubmed.ncbi.nlm.nih.gov/32914846/ https://pubmed.ncbi.nlm.nih.gov/32914846/ http://www.tcc.gov.pk/achievments.php https://www.bibliomed.org/?jtt=2320-4664 https://www.bibliomed.org/?jtt=2320-4664 https://dx.doi.org/10.5455/ijmsph.2014.090720144 https://dx.doi.org/10.5455/ijmsph.2014.090720144 https://www.ncbi.nlm.nih.gov/pubmed/28389225 https://www.ncbi.nlm.nih.gov/pubmed/28389225 https://www.ncbi.nlm.nih.gov/pubmed/28389225 j aziz fatm med den college january june 2021; vol. 3, no. 1 20 10. jena sk, mirdha m, meher p, misra ak. relation of peak expiratory flow rate to body mass index in young adults. muller j med sci res 2017;8:19-23. 11. rehman a, shafiq h, jawed s, behram f. chronic obstructive pulmonary disease (copd) screening is still a challenge in pakistan. j aziz fatm med den college.2019 1(1):18-23. 12. sawant gv, kubde sr, kokiwar pr. effect of smoking on pefr: a comparative study among smokers and nonsmokers in an urban slum community of hyderabad, india. international journal of community medicine and public health. 2017 jan 31;3(1):246-50. 13. mukherjee s, banerjee g, mahapatra abs. peak expiratory flow rate changes with relevant variables in a population of eastern india.indian j physiol pharmacol 2018; 62(3): 372–379. 14. bajentri al, veeranna n, dixit pd, kulkarni sb. effect of 2-5 years of tobacco smoking on ventilatory function tests. journal of the indian medical association. 2003 feb; 101 (2):96-7. 15. kaur h, singh j, makkar m, singh k, garg r. variations in the peak expiratory flow rate with various factors in a population of healthy women of the malwa region of punjab, india. journal of clinical and diagnostic research: jcdr. 2013 jun;7(6):1000. 16. medabala t, b n r, mohesh m i g, kumar m p. effect of cigarette and cigar smoking on peak expiratory flow rate..j clin diagn res. 2013;7(9):1886-1889. doi: 10.7860 /jcdr /2013/6726.3342. authors’ contribution: dr. saifullah shaikh study design, data collection, manuscript writing critically revise and approve the manuscript dr. rabiya ali study design, data collection, statistical analysis, manuscript writing a critical revision of the manuscript and approve the final version. accountable for research work dr hina moazzam data collection, statistical analysis, interpretation of results, revision and approval of the final version all authors are equally accountable for research work and material provided received: 5 jan 2021, revised received: 17 march 2021, accepted: 18 march 2021 saifullah shaikh et al. https://pubmed.ncbi.nlm.nih.gov/24179889/ https://pubmed.ncbi.nlm.nih.gov/24179889/ j aziz fatm med den college january – june 2021; vol. 3, no. 1 13 original article gender wise estimates of hepatitis b and c in the general population of faisalabad, pakistan abid rashid, muhammad farooq bhatti, sultan ayaz abstract objectives: to estimate the frequency of hepatitis b and c and find its association with gender. methodology: this community surveillance was done at surriya majeed trust hospital during january to april 2017. ethical approval was taking from ethical board. free hepatitis camp was arranged at surriya majeed trust hospital faisalabad pakistan in the above mentioned duration. during this survey 1000 subjects of either gender between ≥1 and ≤ 80 years of age, with diverse religions, professional, social and educational backgrounds, were screened for hepatitis b and c. all subjects were self-motivated beyond recording age and gender and were explained with the purpose of the study. consent was obtained and anonymity was assured. in the case of subjects under 18 year consent was taken from the parents/guardians. from each included subject, blood was drawn following aseptic measures. for the qualitative detection of hepatitis b and c virus, immunochromatographic tests were used. all positive cases are reconfirmed by elisa technique. statistical analysis was done by spss version 21. results were presented as mean± sd, frequencies and percentages. chi-square (x2) test was used to analyze association between gender and hepatitis. results: this study consisted of 1000 participants of which 374(37.6%) were male and 622(62.4%) were females. mean age of the study participants was 35.11±13.65.of total 177(17.7%) were hepatitis c positive and 16(1.6%) were positive for hepatitis b. on comparing gender for hepatitis, we found that greater number of females were seropositive for hepatitis c as compared males while hepatitis b was more commonly detected in males. x2 test shows significant association of hepatitis and gender. these findings were strengthened by results of logistic regression analysis with significant pvalue 0.046. conclusion: hepatitis c was more prevalent than hepatitis b in faisalabad district. in terms of gender, hepatitis c was most frequently found in females while hepatitis b was most prevalent in male gender. keywords: community surveillance, gender, hepatitis b, hepatitis c introduction chronic infection of hepatitis is exerting a major health burden globally. this disease is principally targeting the third world countries where it is spreading at a breakneck pace. the world health organization statistics shows around ten hundred thousand mortalities were due to hepatitis which is 2.7 % of total deaths estimation.1 concerning pakistan its prevalence rate is 4.8% and is continuing to increase affecting health providers as well as the community subjects. ___________________________________________________________ dr. abid rashid mbbs, phd professor government college university, fsd dr. muhammad farooq bhatti mbbs, mph medical superintendent. surriya majeed trust hospital, fsd dr. sultan ayaz mbbs, mphil assistant professor government college university fsd correspondence: dr. abid rashid email: drabidrashid37@gmail.com. however, among the provinces of pakistan, in punjab its prevalence is 17% , much on higher side than overall prevalence and major proportion of this high prevalence was from faisalabad district.2 in this region extensive transmission of this disease needs critical understanding of its related epidemiology, cost effective prevention and treatment interventions. this continuous increase is most probably attributed to the low literacy and unsafe medical procedure.3,4 hepatitis is caused by various types of viruses including hepatitis a , b, c, d and e. all these viruses are responsible for targeting the liver causing its damage. hepatitis a and e are not blood born rather transmitted due to poor sanitation problems particularly in pakistan and bangladesh.5 contrary to this; hepatitis b virus (hbv) and hepatitis c virus (hcv) share similar routes of transmission including contaminated blood product exposure, sexual activity or perinatal transmission and blood transfusion via different means.6 hbv belongs to orthohepadnavirus genus a member of the hepadnaviridae family while hcv belongs to flaviviridae. subjects affected by these viruses are j aziz fatm med den college january – june 2021; vol. 3, no. 1 14 diagnosed with the viral load in the blood detected by the pcr or through the antibodies produced resultant to viral exposure. if not timely diagnosed and treated, almost 80% progress to liver cirrhosis ahead of time. due to its asymptomatic nature for longer period of time , many people are left undiagnosed.7,8 however, apart from diagnosis there is a debate that this virus has a gender predisposition towards male population.9 the increasing prevalence of this challenging health crisis, demands essential steps for the awareness and prevention of hepatitis at community level. in this regard screening for hepatitis especially at highly prevalent regions like faisalabad is mandatory to manage and prevent complications of this lethal disease to improve quality of life of the community. hence we aimed to screen the local population of faisalabad district for hepatitis b and c among and we also sought to determine its association with gender. methodology this community surveillance was done at surriya majeed trust hospital in collaboration with lions platinum club faisalabad during january to april 2017 ethical approval was taken from ethical board. permission is given by hospital management after weighing the beneficial effect of this screening on the local community. free hepatitis camp for 15 days was arranged at surriya majeed trust hospital faisalabad, pakistan in the above mentioned duration. during this survey 1000 subjects of either gender between ≥1 and ≤ 80 years of age, with diverse religions, professional, social and educational backgrounds, were screened for hepatitis c and b. all subjects were self-motivated. the purpose and benefits of the study were explained to each participant. subjects were enrolled on a voluntary basis. consent was obtained and anonymity was assured. in the case of subjects under 18 year consent was taken from the parents/guardians. subjects already diagnosed with hepatitis b and c were excluded from the study. from each included subject, blood was drawn following aseptic measures. for the qualitative detection of hepatitis b and c virus, rapid strip immunochromatographic tests (ict) with sensitivity and specificity 99.4% and 99.5% respectively were used. ict follows the principle of lateral flow chromatography immunoassay technique. all positive cases were further confirmed by enzyme linked immunosorbent assay elisa technique in the diagnostic laboratory of the hospital. statistical analysis was done utilizing spss version 21. categorical variables were presented as frequencies and percentages. continuous variable i.e age was present as mean±sd. association between hepatitis and gender was analyzed by chi square test . pvalue ≤0.05 was considered significant. results this study consisted of 1000 participants of which 374(37.6%) were male and 622(62.4%) were females. mean age of the study participants was 35.11±13.65.of total 177(17.7%) were hepatitis c positive and 16(1.6%) were positive for hepatitis b. on gender wise analysis of hepatitis, we found that greater number of females were seropositive for hepatitis c as compared males while hepatitis b was more commonly detected in males. chi square (x2) test shows significant association of hepatitis and gender (table1). these findings are strengthened by logistic regression analysis which showed an odd ratio of 1.37 and beta coefficient of 0.316 for hepatitis c in females predicting 1.37 times more risk for hepatitis c as compared to males (pvalue 0.000). while odd ratio of 0.355 and beta coefficient of -1.037 for hepatitis b was showing females have 0.355 less risk of hepatitis b as compared to males (p-value 0.046). table 1: distribution of hepatitis among gender (n= 1000) gender hepatitis c (anti hcv) hepatitis b (hbsag) seropositive frequency n (%) seronegative frequency n (%) seropositive frequency n (%) seronegative frequency n (%) male (n=374) 56 (15.0) 318(85.0) 10(2.7) 364 (97.3) female (n=622) 121(19.5) 501(80.5) 6 (1.0) 616 (99) p values 0.043* 0.037* association between hepatitis and gender was checked by x2 test. pvalue ≤ 0.05 was considered to be significant. discussion hepatitis b and hepatitis c are chronic blood-borne infectious diseases considered global health issues. prevalence of hepatitis rising at an alarming rate in pakistan involving all the provinces. latest estimates from the world health organization reveal that around 5 and 10 million of pakistani population are affected by hbv and hcv respectively. thousands of new patients are being added every years due to lack of awareness, prevention measures, medical testing and treatment resources including improperly sterilized invasive medical devices, unsafe injections and inadequately screened blood transfusion.10 previous abid rashid et al, j aziz fatm med den college january – june 2021; vol. 3, no. 1 15 epidemiological studies showed punjab is the 2nd highest prevalent province of pakistan and reported higher prevalence of hepatitis c in faisalabad as compared to other regions of punjab. moreover, due to the asymptomatic nature of hcv and lack of routine medical checkup, several hcv infected individuals with the low-grade viremia remain undiagnosed and unaware of their health status for years and therefore, do not pursue treatment until the appearance advanced symptomatic stage of liver impairment.11,12 to curb the huge disease burden, the government of pakistan has announced striving plan to eradicate hbv and hcv infection from the country by 2030. this program aims to provide leadership and coordination to provincial programs in scaling up hepatitis prevention, testing and treatment services.10 keeping this in mind this study was conducted to screen the local population of faisalabad district for hepatitis b and c and highlight its association with gender. current study reveals that 17.7% of the study population was hcv positive and 16 (1.6%) were hbv positive. we found that hcv was more prevalent than hbv infection in our local population. our results are justified with recent past study from faisalabad reported 38.5% and 4% of the targeted population was affected by the hcv and hbv respectively.13 current results are also in line with maan et al, who in his two year retrospective study at district headquarter (dhq) hospital, faisalabad, estimated 21.99% of prevalence of hcv in faisalabad that is slightly higher than other regions of pakistan.12 all above discussed studies are indicating that hcv is more prevalent in faisalabad than hbv infection. on analyzing gender wise frequency of hepatitis, current results reveals that hcv was most commonly found among females than males (19.5% versus 15%). results of chi square test show significant association of hepatitis with gender. this association was confirmed by logistic regression analysis. odd ratio of 1.37 shows females have 1.37 times more risk of getting hcv infection. this finding is in agreement with ramarokoto ce et al, study who reported higher frequency of hcv in females than males (71.42%vs28.57%)in their studied population.14 concerning the gender distribution of hbv infection, current results revealed male predominance as compared to the female (2.7% versus 1.0). the odd ratio of 0.355 shows males possess 0.355 times more risk than females. these findings are compatible with results of khan et al, that reported comparatively high prevalence in male (68.15%) than female population(31.15%).15 public health programs should be arranged concerning assessment of hepatitis infections among the general population, so the precautionary measures should be taken to prevent this lethal disease in our society. limitations: study was carried out in only one region of the faisalabad district. it should incorporate all regions of faisalabad district at government level. conclusion hepatitis c was more prevalent than hepatitis b in faisalabad district. in terms of gender, hepatitis c was most frequently found in females while hepatitis b was most prevalent in male gender. funding source: lions platinum club faisalabad conflicts of interest: authors and funding bodies have no conflict of interest. authors have full access to data. acknowledgement: we are highly grateful to lions platinum club faisalabad for funding. references 1. world health assembly, availability, safety and quality of blood products: report by the secretariat. world health organization. 2010.https://apps.who.int/iris/handle/10665/238 9 [cited: june 15, 2020] 2. amsal a,altaf b, ali f a.seroprevelance of hepatitis b&c and its association with stroke in local population. j aziz fatm med den college. 2019;1:(1):9-12 3. umer m, iqbal m. hepatitis c virus prevalence and genotype distribution in pakistan: comprehensive review of recent data. world j gastroenterol.2016; 22(4):16841700.doi: 10.3748 /wjg.v22.i4.1684. 4. arshad a, ashfaq ua. epidemiology of hepatitis c infection in pakistan: current estimate and major risk factors. critical reviews™ in eukaryotic gene expression2017;27(1):6377.doi:10.1615/critreveukaryotgeneexpr.2017018953. review 5. antony j, celine t. a hospital-based retrospective study on frequency and distribution of viral hepatitis. j glob infect dis. 2014; 6(3): 99–10 6. bigna,jj, kenne am, hamroun, a. et al. gender development and hepatitis b and c infections among pregnant women in africa: a systematic review and meta-analysis. infect dis poverty 8, 16 (2019). https: //doi.org/10.1186/ s40249-0190526-8 7. naz a, mukry sn, naseer i, shamsi ts.evaluation of efficacy of serological methods for detection of hcv infection in blood donors: a single centre experience.pak j med sci. 2018 ;34 (5):12041208.doi:10.12669/pjms.345.15707 8. liao cc, su tc, sung fc, chou wh, chen tl. does hepatitis c virus infection increase risk for stroke? a population-based cohort study. plos one. 2012 ;7(2):e31527. doi: 10.1371 / journal.pone.0031527 hepatitis b&c among gender https://apps.who.int/iris/handle/10665/2389 https://apps.who.int/iris/handle/10665/2389 https://www.ncbi.nlm.nih.gov/pmc/articles/pmc4721999/ https://www.ncbi.nlm.nih.gov/pmc/articles/pmc4721999/ https://www.ncbi.nlm.nih.gov/pmc/articles/pmc4147430/ https://doi.org/10.1186/s40249-019-0526-8 https://doi.org/10.1186/s40249-019-0526-8 https://www.ncbi.nlm.nih.gov/pubmed/30344577 https://www.ncbi.nlm.nih.gov/pubmed/30344577 https://www.ncbi.nlm.nih.gov/pubmed/30344577 j aziz fatm med den college january – june 2021; vol. 3, no. 1 16 9. mohammadali f, pourfathollah a. association of abo and rh blood groups to blood-borne infections among blood donors in tehran-iran. iran j public health. 2014 ;43(7):981989 10. world health organization. hepatitis: 15 million people affected with hepatitis b and c in pakistan: government announces an ambitious plan to eliminate hepatitis. newsroom.2019jul 28; available from https://www .who. int/hepatitis/news-events/pakistan hepatitis elimination-plan /en. [cited on: june,20.2020] 11. ahsan a, khan az, javed h, mirza s, chaudhary su, shahzad-ul-hassan s. estimation of hepatitis c prevalence in the punjab province of pakistan: a retrospective study on the general population. plos one. 2019;14(4):e0214435. 12. maan ma, fatma h, muhammad j. epidemiology of hepatitis c viral infection in faisalabad, pakistan: a retrospective study (2010-2012). afr health sci. 2014; 14 (4):810–155 13. raja ks, naz s, aslam f an. screening of barbers for hepatitis b and c in faisalabad. j aziz fatim med den college. 2020;2(1):8–11 14. ramarokoto ce, rakotomanana f, ratsitorahina m, raharimanga v, razafindratsimandresy r, randremanana r, et al. seroprevalence of hepatitis c and associated risk factors in urban areas of antananarivo, madagascar. bmc infect dis. 2008;8. doi: https://doi.org/10.1186/1471-2334-8-25. 15. khan f, shams s, qureshi id, israr m, khan h, sarwar mt, et al. hepatitis b virus infection among different sex and age groups in pakistani punjab. virol j. 2011;8:225. doi: 10.1186 /1743-422x-8-225. received: 7 dec 2020, revised received: 25 feb 2021, accepted: 01 mar 2021 author’s contribution: dr. abid rashid study design, data analysis and interpretation and write up of results. manuscript writing, critically revised important intellectual content and approved it. dr. muhammad farooq bhatti study design, acquisition of data and manuscript writing. revised and approved the articles. dr. sultan ayaz data collection, manuscript writing revised and approved the articles. all authors are responsible for research work, data integrity of the data and the accuracy of the data analysis abid rashid et al, https://www.ncbi.nlm.nih.gov/pubmed/25909065 https://www.ncbi.nlm.nih.gov/pubmed/25909065 https://www.ncbi.nlm.nih.gov/pubmed/25909065 https://doi.org/10.1186/1471-2334-8-25 j aziz fatm med den college january june 2021; vol. 3, no. 1 21 original article comparison of forced expiratory volume in six seconds and fev1/fev6 ratio among smokers and non smokers aneel aslam, abdul waheed abstract objective: to evaluate and compare force expiratory volume in six seconds (fev6) and fev1/fev6 among the smokers and nonsmokers methodology: this cross sectional study of 200 subjects with age 18-25 years was carried out at karachi institute of medical sciences (kims),khi from september to december 2020. prior the study ethical approval was taken. male smokers and nonsmokers were included in the study. male subjects with pulmonary diseases, cardiovascular diseases and any other skeletal deformities affecting respiration and females were excluded from the study. height, weight and bmi were calculated. fev6 was recorded by a calibrated digital spirometer following the protocol with three readings and highest reading was taken for analysis results: this study was composed of 200 male participants. of the total study population 83 (41%) were smokers and 117(59%) were non -smokers. mean age of the study participants was 21.89 ± 4.8years smokers have lower fev6 and fev1/fev6 values as compared to nonsmokers. significant difference was observed in mean fev6 of smokers and nonsmokers(pvalue =0.002). mean fev1/fev6 was also significantly different among smokers and nonsmokers (pvalue = 0.000*) conclusion: fev6 and fev1/fev6 values were lower in smokers as compared to nonsmokers reflecting decline in lung function. keywords: force expiratory volume in six seconds, fev1/fev6, smokers, non-smokers introduction cigarette smoking is believed as one of the leading health concerns and major cause of avoidable deaths especially in developing countries. according to world health organization (who) estimation more than eight million deaths annually are attributed to tobacco consumption worldwide.1 around 50% of the cigarette smokers ultimately develop to airflow obstruction and decline in lung functions due to repetitive inflammation caused by the reactive oxidative substances generated by smoking.2 spirometric parameters including force expiratory first second (fev1), force vital capacity(fvc) and fev1/fvc are most commonly used parameters for assessing lung function test. fvc maneuver requires active participation and is technically demanding. due to inability to comprehend directions or reluctance to follow the instructions and difficulties in expiring fully in order to provide maximum fvc usually lead to submaximal test results, ____________________________________________________________ dr. aneel aslam mbbs,fcps professor karachi institute of medical sciences (kims),khi dr. abdul waheed mbbs, msc,dmj assistant professor karachi institute of medical sciences (kims),khi correspondence: dr. abdul waheed email: chundrigarwaheed@yahoo.com so these spirometric measurements are not always valid. moreover entire exhalation time can be prolonged in subjects with airflow limitation requiring more physical effort and increased myocardial demand that might cause syncope.3,4even most of these subjects faced difficulty to put sufficient effort at the required period of atleast twenty seconds to obtain reliable fvc and fev1/fvc. fvc is usually underestimated due to poor expiratory effort of subjects, as air flow toward the end of fvc is reduced and not detected by the spirometer.3furthermore, during the procedure, if the subject cannot exhale long enough to clear the lungs to the residual volume, pattern of “pseudo-restriction” is observed, that means concurrently reduction in fev1 and fvc resultant in giving normal picture of fev1/fvc and underestimating airflow obstruction.3 keeping this limitations in mind now researchers are focusing on spirometry maneuvers of shorter duration, forced expiratory volume in first six seconds (fev6) that allowing subjects to stop after short duration of six seconds.3 some studies have suggested that it can be used as surrogate for fvc.5 global initiative for chronic obstructive lung disease (gold) also recommended new researches to explore validate substitute of fev1 and fvc for the diagnosis of asymptomatic patients of airflow obstruction.2 with j aziz fatm med den college january june 2021; vol. 3, no. 1 22 this background this study was designed to compare the fev6 and fev1/fev6 ratio among smokers and nonsmokers. methodology this cross-sectional study was conducted at karachi institute of medical sciences (kims),karachi from september to december 2020. ethical approval was taken from the ethical research committee. it was composed of 200 male subjects of age ranging 18 to 25 years. prior to study, ethical approval was taken from institutional ethical committee. two hundred medical students from 1st year to 3rd year mbbs were selected by convenience sampling technique. relevant information concerning about lifestyle, history of smoking including duration and pack years (number of cigarettes per day by years), medical history about the cough, sputum, chest pain, various allergies, frequent respiratory infections, asthma, chronic obstructive pulmonary diseases (copd), tuberculosis and lung cancer were recorded on structured proforma. participants who smoke more than 100 cigarettes/year in their life regularly were considered smokers and who never smoke or smoke less than 100 cigarettes in their life were enrolled as nonsmokers.6 subjects with cardiorespiratory diseases like tuberculosis, asthma, copd, congestive cardiac and deformity of spine and the thoracic cage such as kyphosis, scoliosis and fused ribs were excluded from the study. informed consent from each participant was taken and then height in meters (m) and weight in kilogram (kg) were obtained by stadiometer. bmi was calculated using formula, weight in kg/height in m2. fev6 was recorded by calibrated digital spirometer following standard guidelines of american thoracic society (ats) and european respiratory society (ers).4 each participant was asked to sit erect, and to breathe normally for about one minute and then asked to breathe as hard as possible and holds the breath. participants while using nose clip, to avoid air leakage, breathes out as quickly and as forcibly as possible into the spirometer through a mouthpiece for the first six seconds to obtain fev6. the maneuver for fev6 and fev1/fev6 was repeated for three times and highest reading was recorded for analysis. statistical analysis statistical analysis was conducted on spss 22 version. descriptive variables including age, height, weight, bmi and fev6 was presented as mean ± standard deviation (sd). mean values for fev6 among smokers and nonsmokers were compared by independent t-test. p-value ≤0.05 considered significant. results this study was composed of 200 male participants. of the total population 83 (41%) were smokers and 117(59%) were non -smokers( figure 1). mean age of the study participants was 21.89 ± 4.8. smokers have lower fev6 and fev1/fev6 values as compared to nonsmokers. significant difference was observed in mean fev6 of smokers and non-smokers. (p-value =0.002). mean fev1/fev6 was also significantly different among smokers and nonsmokers (pvalue = 0.000*, (table 1) figure 1: distribution of study participants table 1: comparison of spirometric parameters among smokers and nonsmokers variables smokers ( n=83) non smokers (n=117) p value 95% confidence interval mean ±sd mean ±sd fev6(l) 3.23±0.616 3.43±0.28 0.002* 0.07964 0.33645 fev1/fev6 0.75±0.97 0.77 ± 0.14 0.000* 0.05438 0.01239 fev6= forced expiratory volume in 6 second, fev1 = forced expiratory volume in first second p value ≤0.05 considered significant discussion trend of smoking is continuously rising all over the world. airway obstruction as a consequence of smoking is well evident. early stages of airway obstruction in smokers can be asymptomatic and cannot be picked by fevi and fvc, so misdiagnosis of airway obstruction is not uncommon in smokers causing significant morbidity and adverse prognosis.7 previous studies have highlighted the importance of fev1/fvc as a screening tool of airway obstruction but new researches have pointed out the submaximal 83 (41%) 117(59%) smokers non-smokers aneel aslam et al. j aziz fatm med den college january june 2021; vol. 3, no. 1 23 determination of fvc value due to failure of subjects to follow proper technique and not exhaling to full extent for a longer time to get validate value for fvc.3 fev6 is now proposed as a reliable substitute tool for fvc and fev1/fev6 ratio can conveniently be used as a viable alternative to fev1/fvc. the benefits for performing this procedure is its shorter duration for performing spirometry tests for fev6 which are also easily executed by patients, hence making it ideal for objectively diagnosing pulmonary disorders and even mild airway obstruction. moreover shortening each forced exhalation manoeuvre to six second would reduce the overall testing time, patient’s effort and fatigue, similarly decrease chance of complication like syncope that is commonly associated with fvc maneuver.8 this below mentioned indian study have proved that the fev6 can be used as a surrogate for fvc and reported 0.75 (75%) as a fixed cut of points for fev1/fev6 for the diagnosis of airway obstruction.8 platino studies, also documented fixed cut off value of 0.75 for fev1/fev6 for airway obstruction.9 in contrast to this, slightly more lower limit of the normal range for fev1/fev6 smokers was about 0.72, reported from the china and 0.73(73%) was reported by 3rd national health and nutrition examination survey (nhanes iii) from united states.10,11 current results show that the smokers have lower fev6 values and fev1/fev6 ratio as compared to the nonsmokers. smokers have border line fev1/fev6 ratio of 0.75 (75%) reflecting airway limitation, as these similar fixed cut of points were reported by singh et al from india and platino studies for airway obstruction.8,9 our results are in line with enright et al study that also reported decline in fev1/fev6 ratio upto 69% in smokers indicating reduced lung functions.11 current results are also confirmed by layoun et al who also reported reduced fev6 and fev1/fev6 in smokers reflecting decline in lung functions.12 it is evident from the previous studies that smoking results in worsening of lung functions and compromised health. however it is preventable morbidity which can be improved with cessation of smoking at any age. early diagnosis of airway obstruction by fev1/fev6 ratio helps in motivation of smokers to quit smoking and to prevent lung damage for spending quality life. limitations: small sample size and short duration of the study is our limitation. it should be conducted on a broader scale for a long duration with control group following strict protocol to validate the results to be implemented on overall population. conclusion fev6 and fev1/fev6 values were lower in smokers as compared to nonsmokers reflecting decline in lung function in smokers. funding source: none. conflicts of interest: none. references 1. world health organization news room. tobbaco. 27 may 2020 https://www.who.int/newsroom/factsheets/detail/tobacco.[cit ed on :6 jan 2021]. 2. global initiative for chronic obstructive lung disease (gold).global strategy for the diagnosis, management, and prevention of chronic obstructive lung diseases(gold) .2018report.https://goldcopd.org/wpcontent/uploads/2017/11/ gold2018v6.0finalrevised20nov_wms.pdf. 3. nwagha u, iyare e, anyaehie u, onyedum c, okereke c, ajuzieogu o. etal. forced expiratory volume in 6 s (fev6) and fev1/fev6 values as a viable alternative for forced vital capacity (fvc) and fev1/fvc values during pregnancy in south east nigeria: a preliminary studyann med health sci res. 2014 jul-aug; 4(4): 516–521. doi: 10.4103/2141-9248.139294. 4. graham bl, steenbruggen i, miller mr, barjaktarevic iz, cooper bg, hall gl, et al standardization of spirometry 2019 update. an official american thoracic society and european respiratory society technical statement..am j respir crit care med. 2019;200(8):e70-e88. doi: 10.1164/rccm.2019081590st. 5. pingul em, de guia ts, ayuyao fg. fev1/fev6 vs fev1/fvc in the spirometric diagnosis of airways obstruction among asians. chest. 2007;132:491c–2. 6. solberg li, asche se, boyle r, . mccarty mc , thoel mj smoking and cessation behaviors among young adults of various educational backgrounds. am j public health. 2007; 97(8): 1421–1426. doi: 10.2105/ajph.2006.098491 . 7. u.s. public health service national heart, lung and blood institute, “global initiative for chronic obstructive lung disease: global strategy for the diagnosis, management, and prevention of chronic obstructive pulmonary disease,” 2010, http://www.goldcopd.com. 8. singh ak, lohia a, "fev1/fev6: a reliable, easy-to-use, and cheaper alternative to fev1/fvc in diagnosing airway obstruction in indian population", international scholarly research notices, vol. 2012, article id 109295, 5 pages, 2012. https://doi.org/ 10.54 02 /20 12/109295. 9. f. w. rosa, r. perez-padilla, a. camelier et al., “efficacy of the fev1/fev6 ratio compared to the fev1/fvc ratio for the diagnosis of airway obstruction in subjects aged 40 years or over,” brazilian journal of medical and biological research, vol. 40, no. 12, pp. 1615–1621, 2007. fev6 & fev1/ fev6 in smokers https://www.who.int/newsroom/factsheets/detail/tobacco https://goldcopd.org/wpcontent/uploads/2017/11/gold2018v6.0finalrevised20nov_wms.pdf https://goldcopd.org/wpcontent/uploads/2017/11/gold2018v6.0finalrevised20nov_wms.pdf https://www.ncbi.nlm.nih.gov/pubmed/?term=nwagha%20u%5bauthor%5d&cauthor=true&cauthor_uid=25221696 https://www.ncbi.nlm.nih.gov/pubmed/?term=iyare%20e%5bauthor%5d&cauthor=true&cauthor_uid=25221696 https://www.ncbi.nlm.nih.gov/pubmed/?term=anyaehie%20u%5bauthor%5d&cauthor=true&cauthor_uid=25221696 https://www.ncbi.nlm.nih.gov/pubmed/?term=onyedum%20c%5bauthor%5d&cauthor=true&cauthor_uid=25221696 https://www.ncbi.nlm.nih.gov/pubmed/?term=okereke%20c%5bauthor%5d&cauthor=true&cauthor_uid=25221696 https://www.ncbi.nlm.nih.gov/pubmed/?term=ajuzieogu%20o%5bauthor%5d&cauthor=true&cauthor_uid=25221696 https://www.ncbi.nlm.nih.gov/pmc/articles/pmc4160672/ https://www.ncbi.nlm.nih.gov/pmc/articles/pmc4160672/ https://dx.doi.org/10.4103%2f2141-9248.139294 https://pubmed.ncbi.nlm.nih.gov/31613151/ https://pubmed.ncbi.nlm.nih.gov/31613151/ https://pubmed.ncbi.nlm.nih.gov/31613151/ https://pubmed.ncbi.nlm.nih.gov/31613151/ https://pubmed.ncbi.nlm.nih.gov/31613151/ https://www.ncbi.nlm.nih.gov/pubmed/?term=solberg%20li%5bauthor%5d&cauthor=true&cauthor_uid=17600256 https://www.ncbi.nlm.nih.gov/pubmed/?term=asche%20se%5bauthor%5d&cauthor=true&cauthor_uid=17600256 https://www.ncbi.nlm.nih.gov/pubmed/?term=boyle%20r%5bauthor%5d&cauthor=true&cauthor_uid=17600256 https://www.ncbi.nlm.nih.gov/pubmed/?term=mccarty%20mc%5bauthor%5d&cauthor=true&cauthor_uid=17600256 https://www.ncbi.nlm.nih.gov/pubmed/?term=thoele%20mj%5bauthor%5d&cauthor=true&cauthor_uid=17600256 https://www.ncbi.nlm.nih.gov/pmc/articles/pmc1931464/ https://dx.doi.org/10.2105%2fajph.2006.098491 http://www.goldcopd.com/ j aziz fatm med den college january june 2021; vol. 3, no. 1 24 10. wang s, gong w, tian y, zhou j. fev1/fev6in primary care is a reliable and easy method for the diagnosis of copd. respir care 2016;61:349–53 11. enright rl, connett je, bailey wc. the fev1/fev6 predicts lung function decline in adult smokers.respir med. 2002 ;96 (6):444-9. doi: 10.1053/rmed.2001.1270. 12. layoun n, saleh n, barbour b, awada s, rachidi s, al-hajje a, et al. waterpipe effects on pulmonary function and cardiovascular indices: a comparison to cigarette smoking in real life situation. inhal toxicol. 26(10):620–627. received: 01 jan 2021, revised received: 11 march 2021, accepted: 15 march 2021 author’s contribution: dr. aneel aslam study design, data collection, and data analysis interpretation of results, critically revise the manuscript for all intellectual content and make all necessary revision in manuscript. check and correct all the references carefully and approved the article. dr. abdul waheed study design, data collection, manuscript writing, revise and approve the article. all authors are equally accountable for research work and material provided aneel aslam et al. https://pubmed.ncbi.nlm.nih.gov/12117045/ https://pubmed.ncbi.nlm.nih.gov/12117045/ 30 january – june 2023, vol,5. no.1 j aziz fatm. med den college original research to find the correlation of immunoglobulin g with severity of psoriasis rukhsan khurshid, saima rasheed, shakil ahmed, huma ashraf, gul-e-raana, maira mahmood abstract objectives: to find the correlation of immunoglobulin g with severity of psoriasis. methodology: this cross-sectional descriptive study was conducted at sir ganga ram hospital lahore/niazi teaching hospital sargodha. study duration was six months from january 2020 to june 2020. one hundred patients of psoriasis (confirmed by dermatologist) were included in the study. questionnaire based on age, gender, duration of illness, type and severity of problem etc and biochemical test including immunoglobulin g were filled by consented patients. the study comprised into patients and controls groups. fifty age matched subjects with no history of skin disease were taken as controls. for immunological assessment, igg was measured by the technique of elisa results: mean age of developing of disease was in the range of 36 to 43 years. a few patients have family history with a problem of asthma. high severity of index (59 to 61) in both genders with duration of disease was 4 to 6 years. a direct correlation between level of igg and disease severity was observed. conclusion: increased level of immunoglobulin g and its direct correlation with severity of psoriasis may suggest an activation of 2nd immune defense that try to reduce the severity of disease. keywords: psoriasis, acute phase, chronic phase, immunoglobulins. introduction psoriasis vulgaris is a chronic, immune-mediated, inflammatory, skin problem found in 12% of the population. about 90% of cases of psoriasis cases were plaque-type psoriasis. the typical clinical sign and symptoms are erythematous, pruritic plaques enclosed in shiny scales cover many parts of skin including surfaces of the limbs, trunk and the scalp.1 the two peaks of onset of psoriasis are between the age 20 to 30 years and between the age of 50 to 60 years and t equally in both sexes.2 this ailment may be associated with various comorbidities including malignancy and cardiovascular problem.3 the disease has poor impact on quality of life including rukhshan khurshid, phd assistant professor sharif medical and dental college lhr, pakistan saima rashid, m.phil assistant professor niazi medical and dental college, sargodha. pakistan shakil ahmed, professor aziz fatima medical and dental college fsd, pakistan huma ashraf, m.phil associate professor cmh lahore medical college & institute of dentistry, lhr, pakistan gul-e-raana, phd professor sharif medical and dental college lhr, pakistan maira mahmood, m.phil, phd student , university of lahore, lhr, pakistan correspondence dr.rukhshan khurshid email: rakhshan99@yahoo.com impact on quality of life including the problems of anxiety, depression, stigma and in some cases suicidal deeds.4,5 apart from genetic propensity, risk factors that activate psoriasis include infection, dugs, infection, metabolic issues, stress, smoking, and sunlight. drugs that can aggravate psoriasis include betablockers, anti-malarian, calcium channel blockers, captopril, lipid lowering, interferon and penicillin.6 these factors affect body immune system that results in the development of extra blood vessels and enhances no of skin cells.7 psoriasis vulgaris is arbitrated by the cells /molecules of both the adaptive and innate immune systems. the activated pathways of immune system in psoriasis presents intensifications of immune circuits in normal skin of human. these include epidermal keratinocytes the major contributor in innate form of immunity, which can stimulate and stop types of t cells which are employed to the skin.8 both cellular adaptive and humeral adoptive immunity are explained in with psoriasis.9 five major circulating immunoglobulin in sera iga, igg, igm, igd, and ige are formed in plasma or β cell and their synthesis is activated by an immune response to the foreign elements/microorganisms. igg is principally present in extracellular fluid and blood circulation and efficiently opsonizes pathogens and stimulate the complement system. since the circulating concentrations of antibodies 31 rukhsan khurshid et al january – june 2023, vol,5. no.1 j aziz fatm. med den college igg were related with the severity of ailment of psoriasis it is believe that in disease psoriasis a pathogenetic relationship along with systemic inflammation may exist.9 psoriasis is a wearisome disease for patients. it may affect perceptions of patients for themselves and this may initiate psychologic problems like depression. patients with some degree of skin disease may still have noteworthy psychosocial problems. this study designs to study to find the correlation of immunoglobulin g with severity of psoriasis. methodology this cross-sectional descriptive study was conducted at sir ganga ram/hospital lahore and niazi teaching hospital sargodha. study duration was six months from january 2020 to june 2020. one hundred patients of psoriasis (confirmed by dermatologist) were included in the study. age range of patients was 35-45 years. study was included both genders. patients with psoriasis— aged from 35 to 45 years, both genders with healthy status were included in the study. patients with other dermatological diseases were excluded from the study. questionnaire based on age, gender, duration of illness, type and severity of problem etc and biochemical test including immunoglobulin g were filled by consented patients. the study comprised into patients and controls groups. 50 age matched subjects with no history of skin disease were taken as controls. for immunological assessment, igg was measured by the technique of elisa. letter of irb was taken by research development ethical committee of niazi teaching hospital sargodha, statistical analysis data was analyzed by spss 19.0. data presented were the means and standard deviations. variables of both patients and controls were compared by independent student -ttest. pearson correlation coefficients were applied to find the correlation between immunoglobulin g p0.05 was considered as statistically significant. results mean age of male patients included in this study is 36 years and of female patients is 43.00 year. majority of the male and female patients belong to middle class and few belong to lower class. family history shows that most of male and female patients have no family history. on the other in male patients some shows asthma, diabetes, whereas in female some patients shows joint pain and asthma (table 1). level of immunoglobulin g was significantly increased (p <0.001) in male patients as compared to the level of immunoglobulin g of their control subjects. on the other the severity of index in male patients was 59.60 percent and the duration of disease of patients was 4.48 years. a direct correlation between igg and disease severity was observed in male subject with r-value 0.3768 (table 2 fig 1). level of immunoglobulin g was significantly increased in female patients as compared to the level of immunoglobulin g of their control subjects. on the other the severity of index in patients was 61.40 percent and the duration of disease of patients was 6.43 years. a direct significant correlation between igg and disease severity was observed in female subject with r -value 0.5203 and significant difference (p<0.01) (table 3 &fig 2). table 1: physical characteristics of male/female patients with psoriasis age (years) 36.562.85 43.002.69 body weight (kg) 72.602.18 73.481.82 blood pressure (mm/hg) 120/750.92/0.94 125/802.09/1.73 socioeconomic status middle class (22), lower middle class (3) middle class (15) lower middle class (10) diet mixed food (10) junk food (12) vegetable/meat food product (2) mixed food (5) vegetable food (14) fatty/meat food (4/2) occupation job (16) student (6) retired (3) house wife (23) job (2) family history family history (4) no family history (21) family history (4) no family history (21) any other disease asthma/dm (2) allergy (2) no other disease (20) tropical disease (1) joint pain (2) asthma (2) no other disease values are expressed as means.e.m. no of cases in parenthesis table 2: biochemical parameters, severity of disease index and duration of disease in male patients with psoriasis and its comparison with control subjects parameters male patients (25) control subjects (20) immunoglobulin table g (gm/dl) 13.740.49** 10.560.80 severity of disease index (%) 59.604.08 duration of disease (years) 4.480.62 **p<0.001= highly significant differenc 32 correlation of immunololbulin g with severity of psoriasis january – june 2023, vol,5. no.1 j aziz fatm. med den college values are expressed as means.e.m. no of cases in parenthesis table 3: biochemical parameters, severity of disease index and duration of disease in female patients with psoriasis and its comparison with control subjects parameters female patients (25) control subjects (20) immunoglobulin g (gm/dl) 14.811.12** 12.000.16 severity of disease index (%) 61.404.15 duration of disease (years) 6.434.85 **p<0.001= highly significant difference values are expressed as means.e.m. no of cases in parenthesis discussion innate and adaptive immune systems are thought to be responsible for pathogenesis of psoriasis, while well-recognized environmental factors like smoking and emotional stress can modify disease severity.10 according to our study male patients may develop psoriasis earlier (age 36 year) than female (43 years). a few patients have family history with joint pain and asthma. however, a study observed that the mean age of patients was 50.4 year and female were more respondents than male. study also found that family history is not the reason of developing disease in both genders.11 level of immunoglobulin g was significantly increased in both genders of psoriasis. we agreed with the studies who found humoral changes i.e increased immunoglobulin along with igg in patients with psoriasis.12 it is demonstrated than various humoral changes occurred in psoriatic skin. however a study stated that in psoriasis patients, especially those with severe disease, high values of immunoglobulin a. immunoglobulin e and iggalong with antinuclear antibodies was seen. these antibodies may be seen in the stratum corneum, where they may activate complement system and attract neutrophils.13 a study found a rise in the values of serum igg activity along with a rise in the activity of anti-igg in the serum of majority of the patients with psoriasis. this showed the role of auto-immune course in psoriasis.this study concludes that the autoantibodies are found to be present in psoriasis patients or latent autoimmune diseases that may develop in psoriasis patients without any clinical sign and symptoms14. we observed high severity of index (59 to 61) in both male /female patients with duration of disease was 4 to 6 years. however a study found that majority of patients has moderate to severity of index with a duration of 8 to 10 year.15 another study stated that based on body surface area / psoriasis area and severity index criteria, moderate-to-severe psoriasis was proved in 79 % of patients.6 we observed a direct correlation between igg and disease severity in both gender. a study also observed that igg were specifically raised in psoriatic patients and correlated with disease severity, signifying that an underlying pathogenic relationship and a contribution to systemic inflammation exists.17 a study demonstrated that many cells of the immune system shows the receptors for the constant part or (fc) region of immunoglobulins g recognizes immune complexes and ig-opsonized cells. it is proposed that heterogeneous molecules are take part in regulating and executing antibody-mediated responses, including cytokine release, respiratory burst, internalization, and killing.18,19 psoriasis is proposed to be an autoimmune ailment caused by improper activation of the cellular igganti-iga antibody levels, modification in function of polymorph nuclear leukocytes reduces the no of t cells, and a rise in activity of beta cells.2 33 rukhsan khurshid et al january – june 2023, vol,5. no.1 j aziz fatm. med den college conclusion increased level of immunoglobulin g and its correlation with severity of disease may suggest an activation of 2nd immune defense that try to reduce the severity of disease. conflict of interest: none funding source: none references 1. sârbu mi., georgescu sr., tampa m., sârbu ae., simionescu o. biological therapies in psoriasis-revisited. rom. j. intern. med. 2018;56(2):75–84. doi: 10.1515/rjim-2017-0045 2. mitran mi., mitran ci., sârbu mi., benea v., tampa m., georgescu sr. therapeutic challenges in a case of psoriasis with nail onset. j. mind med. sci. 2017;4(3):186–192. doi:10.22543/ 7674.42.p186192. 3. kim wb, jerome d, yeung j. diagnosis and management of psoriasis. can fam physician. 2017;63(4):278-285. pmid:2840 4701; pmcid: pmc5389757. 4. tampa m, sarbu mi, mitran mi, mitran ci, matei c, georgescu sr. the pathophysiological mechanisms and the quest for biomarkers in psoriasis, a stress-related skin disease. dis markers. 2018; 2018:5823684. doi: 10.1155/2018/5823684. 5. georgescu sr, tampa m, caruntu c, sarbu mi, mitran ci, mitran mi, et al. advances in understanding the immunological pathways in psoriasis. int j mol sci. 2019 ;20(3):739. doi: 10.3390/ijms20030739. 6. schadler ed, ortel b, mehlis sl. biologics for the primary care physician: review and treatment of psoriasis. dis mon. 2019;65(3):51-90. doi: 10.1016/j.disamonth.2018.06.001. 7. ala`a hussein t. study the some concentrations of immunoglobulins igg,igm ,iga in psoriasis patients. j kerbala uni. 2013; 11(2): 98-103 8. lowes ma, suárez-fariñas m, krueger jg.immunology of psoriasis. annu rev immunol. 2014;32:227-255. doi:10.1146/ annurev-immunol-032713-120225 9. schön mp. adaptive and innate immunity in psoriasis and other inflammatory disorders. front. immunol. 2019; 10:1764. doi: 10.3389/fimmu.2019.01764 10. zeng j, luo s, huang y, lu q. critical role of environmental factors in the pathogenesis of psoriasis. the j derma 2017;44 (8): 863-872. 10.1111/1346-8138.13806 11. kasumagic-halilovic e. total serum immunoglobulin e levels in patients with psoriasis. mater sociomed. 2020;32(2):105107. doi:10.5455/msm.2020.32.105-107 12. afifi l, danesh mj, lee km, beroukhim k, farahnik b, ahn rs et al..dietary behaviors in psoriasis: patient-reported outcomes from a u.s. national survey. dermatolther (heidelb). 2017;7(2):227-242. doi:10.1007/s13555-017-0183-4 13. melini v, melini f. gluten. free diet: gaps and needs for a healthier diet. nutrients. 2019;11(1):170. doi:10.3390/nu11010 170 14. singh s, singh u, singh s. prevalence of autoantibodies in patients of psoriasis. j clin lab anal. 2010;24(1):44-48. doi: 10.1002/jcla.20365. 15. pate mb, smith jk, chi ds, krishnaswamy g. regulation and dysregulation of immunoglobulin e: a molecular and clinical perspective. clinmol allergy. 2010;8:3. doi: 10.1186/14767961 61-8-3 16. khan jm, rao su, muhammad ur, janjua w. association between psoriases and celiac disease related antibodies. j ayub med coll abbottabad 2014;26(2):203–206. 17. yuan y, qiu j, lin zt, et al. identification of novel autoantibodies associated with psoriatic arthritis. arthritis rheumatol. 2019; 71(6): 941951. doi: 10.1002/art.40830 18. garcía-diez a, foraster cf, sebastián fv, tudela ll, llach xb, fernández gs. what characterizes the severity of psoriasis? results from an epidemiological study of over 3,300 patients in the iberian region. dermatology. 2008;216(2):137-151. doi: 10.1159/000111511. 19. arman m, krauel k. platelet igg fc receptor fcγriia in immunity and thrombosis. j thromb& hemostasis 2015;13(6): 893-908. 20. azarsiz e, ertam i, karaca n, aksu g, alper s, kutukculer n. igg-anti-iga antibodies: an autoimmune finding in patients with psoriasis vulgaris. minerva med. 2012 jun;103(3):183-187. author’s contribution rukhshan khurshid study design, data, collection data analysis and interpretation of results and manuscript writing. approved final version saima rasheed data acquisition, manuscript writing, reviewed and approved the manuscript. shakil ahmed study design, revise manuscript critically, make revisions and approve it huma ashraf study design, data collection, revise draft and formatting of final manuscript. revised and approve the final manuscript. gul-e-raana study design, data collection, revised and approve the final manuscript. maira mahmood study design, data collection and approve final manuscript all authors are equally accountable of accuracy, integrity of all aspects of the research work. date of submission: 20-12-2021 revised: 23-06-2022 accepted: 20-12-2022 j aziz fatm med den college july – december 2022, vol. 4. no. 2 20 original article psychological sequelae of covid-19: the mediating role of family communication as a protective factor umaiza bashir, ayesha jabeen abstract: objectives: to assess the mediating role of family communication between the relationship of psychological strengths or sequelae and anxiety symptoms in general population during lockdown in covid-19 among. methodology: a cross-sectional research design was used to assess a sample of age range 18 years to 60 years during a period of march 2020july 2020 after taking ethical approval by a institutional review board of university. the measures of the study including demographic variables form, indigenous scale for psychological strengths and depression anxiety stress scale (dass) was used to measure the anxiety in population. the family communication scale was used to measure the mediating effect of communication within family members. using convenient sampling online google form was generate and from 371 participants’ data was collected, in which adult general population was included. result: the present study showed that there was a significant relationship between the study variables, and family communication indicated partial mediating role between psychological sequelae and anxiety symptoms. conclusion: it can be concluded that to better deal with the anxiety related to corona virus disease positive perspective is important and family bonding and communication play significant role in increasing psychological strengths. keywords: psychological strengths, corona virus, anxiety symptoms, family communication introduction the covid-19 pandemic has a great risk of catching the virus, which resulted in a strict lockdown and posed quarantine worldwide.1 quarantine living has been devastating around the globe, there is the anxiety of basic survival and whether one can protect themselves.1 people are having fear of falling sick, helplessness, and stigma of being a corona virus patient.2 it showed the general public experiencing a wide range of psychological problems because of this epidemic just like the previous outbreaks of infections.3 umaiza bashir msc lecturer clinical psychology school of professional psychology university of management and technology, lhr, pakistan ayesha jabeen msc assistant professor clinical psychology, school of professional psychology university of management and technology, lhr, pakistan correspondence: umaiza bashir email: umaiza.bashir@umt.edu.pk one study reported that during an influenza outbreak in past, almost 30% of the population reported fear and worried thoughts about contracting the virus.4 with the closure of schools, markets, and every public activity people are bound to remain at home, which makes individuals experience negative emotions.5 more specifically, there is fear of self-isolation associated with depression, anxiety, and stress especially within vulnerable persons.6 however, most people are resilient even when facing difficult situations like disease outbreaks. being resilient is one of the psychological adjustment components, although there is a large ratio of reported psychopathology among people who expose to traumatic life events also there are factors that make them psychologically strong to cope and deal with stressful situations. to maintain ongoing mental and physical care, family and interpersonal resources are those factors that can be useful especially in uncertain threats like covid-19.7 almost every individual is quarantine with the family members at home, mailto:umaiza.bashir@umt.edu.pk j aziz fatm med den college july – december 2022, vol. 4. no. 2 21 umaiza bashir et al that’s why it becomes very important to understand the psychological strengths at the family level and know the role of a family communication to decrease adverse effects of psychological sequelae. in the light of strengths and adaptability approach families help to be resilient to disruption in the face of change and adaptive in the face of crises.8 better family communication facilitates adjustment and response towards the crises and stress, better clarity of problem, open emotional expression and family warmth are one of the few dimensions which make healthier communication among family members.9 the current covid-19 epidemic situation is inducing continuous stress, therefore timely understanding of mental health crisis and protective factors for coping is need of the time. moreover, according to theoretical models of psychological adjustments, the role of resilience factors like the family may change the perspective of adverse situations. thus, this study is an attempt for highlighting the importance of paying attention to family communication as a regulatory and modifying strategy to use in response to changing situational anxiety of the corona virus. methodology the current study used a cross-sectional research design, which consisted of 371 participants of the age range of 18 to 60 years old adult general population. this study was conducted during a period of march 2020july 2020 in department of clinical psychology, university of management and technology lahore after taking ethical approval from institutional review board of university. (ref icpy/20/140) data was collected from general pakistani population using convenient sampling technique. questionnaire was constructed on google form. the goggle form link was shared among the participants through personal contacts on what’s app. subjects, who were illiterate and below 18 above 60 years were excluded from the study. three assessment scales were used including, a 10-item family communication scale, to know about the communication patterns among family members, this scale has shown good reliability (α = 0.90).10 indigenous psychological strengths scale with strong psychometric properties (α = 0.93) was used to assess positive perspectives and adjustments against covid-19.11 this scale has 21 items with 3 factors named revitalization of self, family/relationships bonding and religion and spirituality. to measure the anxiety symptoms of individuals in time of pandemic the subfactor of anxiety containing 7 items on 4-point likert scale (0=did not apply to me at all to (3=applied to me very much or most of the time), was used from depression, anxiety, stress scale (dass).11 the total score of the dass-21 ranges between 0 and 63.11,12 this scale also had sound psychometric properties with high reliability in english language (α = 0.93).12 at the beginning of the questionnaire, a brief statement on consent and confidentiality was given. questionnaire also include questions regarding demographic variables including age, gender, education, family system, and marital status. there was no question concerning identity of participants to maintain confidentiality. filling the questionnaire implied permission to be included in the study; so no formal written permission was sought from participants. spss version 22 was used to analyzed the data in which descriptive analysis was used and in inferential statistical analysis pearson correlation was administered to assess the relationship. hayes process analysis was used to see the mediating effect of family communication. results study was comprised of 371 participants of both gender with mean ± sd of 40.6 ±6.7 data represented in the table 1 showed that in the study sample female participants were more in number (73%) as compared to males. it also depicted that graduate education level (195) and unmarried participants (302) were more in data. most of the participants live in a nuclear family system (69%). most of the participants of the study were in their early adulthood phase. the mean age of participants was 24.7 and standard deviation was 6.7. the table 2 showed the relationship between the psychological strengths (ps) and family communication to be positively significant (r = 0.53), and the association of ps with anxiety symptoms was identified as negative but weak j aziz fatm med den college july – december 2022, vol. 4. no. 2 22 role of family as protective factors in covid (r = -0.15). whereas, family communication has a significant negative relationship with anxiety symptoms (r = -0.21). these results revealed that the individual with healthy family communication will have less anxiety related to covid-19 and a more positive approach. mean & sd scores for psychological strengths, family communication and anxiety symptoms were 44.06±11.5137.19±8.17, 4.45±4.23 respectively. table 1: demographic characteristics gender, age category, education of the participants (n=371) variables population n (%) gender male 99(26.7) female 272(73.3) education school and college 27(7.5) graduate-level 195(52.6) post graduate level 149(40.2) marital status married 69(18.5) unmarried 302(81.4) family system nuclear 256(69) joint 115(31) f= frequency, %=percentage simple mediation analysis was carried out to find out the mediating role of family communication between psychological strength and anxiety. table 2: inter-correlations between psychological strengths, family communication and anxiety symptoms in general population (n = 371) variables fc (r) as (r) ps 0.53*** -0.15 fc -----.21** ps: psychological strengths, fc: family communication, as: anxiety symptoms, r= pearson's correlation coefficient, p value ≤0.05, **p < .001*** figure 1: simple mediation analysis model results of the study indicated that psychological strength was found to be a significant predictor of family communication as a = 0.37, se = 0.05=3, p < 0.001 and the anxiety was found to be significant predictor of family communication as b = -0.09, se = 0.03 p < 0.01. the findings of the study revealed that the family communication was found to be fully mediating the association of psychological strength and anxiety as the c’ model indicated b = -0.02, se = 0.02, p>0.05. the mediation effect of family communication was found to be non-significant which depicted the full mediation of the model while the values of c were b = -0.05, se = 0.01, p < 0.01. the results of mediation analysis highlighted the role of family communication as a full mediator of the model while controlling the direct effect which supported the mediational hypothesis. table3: role of family communication as a mediator psychological strengths and anxiety (n=371) consequent m(fc) y(anxiety) antecedent β se p c β se p ps (x) a 0.37 0.03 0.001 *** -0.02 0.02 0.32 family com. (m) ------b -0.09 0.03 0.003** r 2 =0.28 r 2 =0.04 f(1,369)=144.75, p=.001*** f(2,368)=9.04, p=.001*** ps= psychological strengths, family com= family communication, β = beta, se=standard error, p>0.05, **p <0.01, ***p <0.001 discussion a plethora of literature concerning psychological and social risk factors exacerbating the physical impact of covid symptoms also raised the attention of researchers towards finding the protective factors that could mitigate the disease effects. numerous factors played their role to rescue people from the devastating corona impacts; two among them were psychological strengths and family communication included in the present study.13 apprehensions, fear, anxiety, and stress raised by the pandemic stirred hope, bravery, and resilience of many. the psychologically resilient individuals can face adversity of the situation in an adaptive manner.14 however, certain factors like poor family relations and maladaptive communication may family communication (m) psychological strength (x) anxiety (y) c = -0.05** b = -0.09** c’= -0.02 a = -0.37*** j aziz fatm med den college july – december 2022, vol. 4. no. 2 23 umaiza bashir et al setback even robust individuals. current study’s results revealed that positive family communication reduce anxiety symptoms during the pandemic. these results are also supported by the previous studies which ruled out that effective communication fosters understanding, coping, and feelings of support from around and therefore mitigates the psychological uproar stemming from pandemic uncertainties. the increase of work from home demand, and imposed lockdown enforced the time together thus providing families with interference opportunities, negative emotional experiences, and shadowing the constructive communication chances.15 this not only increased the magnitude of interfamilial relational turbulence but also left a negative perception about togetherness. previous literature has shown that stress and especially covid-19 fear and stress effect the mental health of an individual, this negativity weakens the psychological immunity and raises the vulnerability of experiencing anxiousness in the prevailed situation of adversity.16 in contrast, effective communication that entails warmth, love, understanding, expression of positivity, and productive control of emotions and behaviors promote wellbeing and solidify the roots of psychological strength and resilience.14 these same results are also depicted by the current study. such individuals utilize intra-individual and interpersonal capacities to face general and specific life upheavals. conclusion the study has revealed the mediating role of family communication between psychological strengths and anxiety suggesting that interplay of personal and social factors provides resources for a physical and psychologically strained battle field. references 1. rehman r, jawed s, ali r, noreen k, baig m, baig j. covid19 pandemic awareness, attitudes, and practices among the pakistani general public. front public health. 2021; 9:588537. doi: 10.3389/fpubh.2021.588537. 2. smith lg, gibson s. social psychological theory and research on the novel coronavirus disease (covid‐19) pandemic: introduction to the rapid response special section. br j soc psychol.2020;59(3):571–583. doi: 10.1111/bjso.12402. 3. simione l, gnagnarella c. differences between health workers and general population in risk perception, behaviors, and psychological distress related to covid-19 spread in italy. front psychol. 2020;11:2166. doi: 10.3389/fpsyg.2020.02166 4. horesh d, brown ad. traumatic stress in the age of covid-19: a call to close critical gaps and adapt to new realities. psychol trauma. 2020;12(4):331–335. doi: 10.1037/tra0000592 5. yamaguchi k, takebayashi y, miyamae m, komazawa a, yokoyama c, ito m. role of focusing on the positive side during covid-19 outbreak: mental health perspective from positive psychology. psychol trauma. 2020;12(s1):s49-s50. doi: 10.1037/tra0000807 6. peconga ek, gauthier gm, holloway a, walker rs, rosencrans pl, zoellner la, et al. resilience is spreading: mental health within the covid-19 pandemic. psychol trauma.2020;12(s1):s47-s48. http://dx.doi.org/10.1037/tra0000874 7. chen s, bonanno ga. psychological adjustment during the global outbreak of covid-19: a resilience perspective. psychol trauma: theory, research, practice, and policy. 2020;12(s1): s51-s54.doi:10.1037/tra0000685. http://dx.doi.org/10.1037/tra0000685 8. lassri d, desatnik a. losing and regaining reflective functioning in the times of covid-19: clinical risks and opportunities from a mentalizing approach. psychol trauma: theory, research, practice, and policy.2020;12(s1): s38-s40. http://dx.doi.org/10.1037/tra0000760 9. mancini ad. heterogeneous mental health consequences of covid-19: costs and benefits. psychol trauma: theory, research, practice, and policy. 2020;12(s1): s15-s16. http://dx.doi.org/10.1037/tra0000894 10. villarreal-zegarra d, paz-jesús a. a family cohesion, adaptability and composition in adolescents from callao, peru. propósitos y representaciones.2017;5(2):21-64. http:// dx.doi.org/10.20511/pyr2017.v5n2.158 11. lovibond pf, lovibond sh. the structure of negative emotional states: comparison of the depression anxiety stress scales (dass) with the beck depression and anxiety inventories. behaviour research and therapy.1995 ;33(3):335-343. 12. ali am, hori h, kim y, kunugi h. the depression anxiety stress scale 8-items expresses robust psychometric properties as an ideal shorter version of the depression anxiety stress scale 21 among healthy respondents from three continents. front psychol. 2022; 13:799769. doi: 10.3389/fpsyg.2022.799769 13. theiss ja. family communication and resilience. journal of applied communication research. 2018;46(1):10–3. 10.1080/00909882.2018.1426706 14. knoster k, howard ha, goodboy ak, dillow mr. spousal interference and relational turbulence during the covid-19 pandemic. communication research reports. 2020;37(5):254–262. https://doi.org/10.1080/08824096.2020.1841621 15. monk jk, ogolsky bg. contextual relational uncertainty model: understanding ambiguity in a changing sociopolitical context of marriage. journal of family theory & review. 2019;11(2):243–261. https://doi.org/10.1111/jftr.12325 16. hernandez ra, colaner c. “this is not the hill to die on. even if we literally could die on this hill”: examining communication ecologies of uncertainty and family communication about covid-19. american behavioral scientist.2021;65(7):956–975. https://doi.org/10.1177/00027642219. j aziz fatm med den college july – december 2022, vol. 4. no. 2 24 role of family as protective factors in covid authors’ contribution umaiza bashir study design and concept, the acquisition, analysis, or interpretation of data for the work; drafting the manuscript revising critically for important intellectual content. ayesha jabeen study design and concept, data collection and analysis, or interpretation of data, manuscript writing, revise and approve the manuscript. all authors are equally accountable for accuracy, integrity of all aspects of the research work and approved the manuscript date of submission: 03-03-2022 revised: 04-12-2022 accepted: 09-12-2022 j aziz fatm med den college jan-june 2020; vol.2, no 1 4 original article frequency of agenesis of palmaris longus muscle in medical students of faisalabad quddus ur rehman, usman latif, faiqa haris, faiza liaqat abstract objective: to find out frequency of agenesis of palmaris longus (pl) of medical students of faisalabad. methodology: this cross-sectional study was conducted from 1 st to 31 st october 2019 at the anatomy department of a private medical college of faisalabad. two hundred and two medical students of age ranging from 18-22 years were evaluated for agenesis of pl by standard schaeffer’s test. findings were confirmed by thompson’s test, pushpakumar’s “two-finger sign” method, mishra’s test i, and mishra’s ii test. data was analyzed by spss version 21. frequencies and percentages for pl agenesis were obtained and compared by chi square test. p value ≤ 0.05 was considered to be significant. results: the pl muscle was present in 155 students (76.3%). the frequency of agenesis was noted in 47 students (23.6%). bilateral agenesis was seen in 16 students (7.9%) while 31 subjects (15 %) had unilateral agenesis. twenty-nine (29.5%) male students had agenesis of palmaris longus. out of which bilateral and unilateral agenesis found in 7 (6.8%) and 22 (21%) male students respectively. in comparison to this 18 (17.3%) female students had agenesis of palmaris longus. out of which bilateral and unilateral agenesis found in 9(8.6%) and 9(8.6%) female students respectively. conclusion: unilateral agenesis of pl is more common than bilateral agenesis. agenesis of pl is more frequent in males as compared to females. keywords: palmaris longus muscle, agenesis, schaeffer’s test. introduction the palmaris longus (pl) is a slender, most variable fusiform superficial flexor muscle of the anterior compartment of forearm. it originates at the medial epicondyle of the humerus and inserts into the palmar aponeurosis through its long tendon. 1 palmaris longus is considered to be a tensor of palm’s subcutaneous tissue. it serves as an anchor of skin and fascia and tenses palmar aponeurosis to resist horizontal shearing forces. pl is supplied by median nerve and branches of ulnar artery. 2 various studies show structural variations in palmaris longus from unilateral or bilateral agenesis, merging with other muscles, presence of an accessory muscle belly to multiple insertion points etc. different ___________________________________________ dr. quddus ur rehman, mbbs, fcps professor anatomy aziz fatimah medical and dental college, fsd dr. usman latif, mbbs, fcps professor anatomy aziz fatimah medical and dental college, fsd dr. faiqa haris, mbbs demonstrator anatomy aziz fatimah medical and dental college, fsd dr. faiza liaqat, mbbs demonstrator pharmacology independent medical college, fsd correspondence: dr. faiqa haris email: drfqharis@gmail.com common reason for median and ulnar nerve compression due to its relationship with these nerves. developmental pathways of the pl might be responsible for morphological variation of the muscle in adults. 3 the anatomical variation in morphology in multiple studies show that its abnormal positioning causes carpel tunnel syndrome. 4,5 when palmaris longus enters in guyon’s canal, it causes compression of ulnar artery and nerve leading to guyon canal syndrome. 6 the tendon of palmaris longus is an important landmark for palm access in treatment of carpal tunnel syndrome. it is also an important land mark for distal radial fracture. 6 furthermore, it is a perfect choice for grafts in reconstructive, plastic and cosmetic surgeries due to its retrogressive characteristics having short belly and long tendon. 7 the graft of the tendon has no effect on the functionality of the upper limb 7 , as people with absence of this muscle reported no functional disability. however, its presence plays a noteworthy role in reconstructive plastic surgery as a donor tendon for grafting. 7,8 objectives: to find out frequency of agenesis of palmaris longus (pl) of medical students of faisalabad. methodology this cross-sectional study was conducted in the anatomy department of faisalabad based private faiqa haris et al. j aziz fatm med den college jan-june 2020; vol.2, no 1 5 medical & dental college. the study was conducted from 1 st to 31 st october 2019 after taking ethical approval from institutional ethical committee (iec/774-19). the male and female students of age ranging 18-22 years were included in the study. two hundred and two participants were recruited by convenient sampling technique. students who had history of any injury to hand & forearm, contracture of forearm muscles, any disability of hand or forearm and any surgery on forearm or hand were excluded from the study. after explaining the objective of study and taking informed consent, medical students were examined for presence or absence of pl tendon initially by the schaeffer’s test (standard technique) and later on the findings were confirmed by four additional tests explained below and the results were recorded. schaeffer’s test : was performed by asking the subject to oppose his/her thumb against the little finger and then flexing his/her wrist against resistance 9 . thompson’s test was performed by asking the subject to make his/her hand fist and then flexing the wrist and then finally the thumb is opposed and flexed over the fingers. 10 mishra’s test i test, all metacarpophalangeal joints are passively hyperextended by the examiner then the subject is asked to actively flex his wrist. mishra’s test ii was performed by asking the subject to abduct the thumb against resistance while keeping the wrist in slight palmar flexion. 11 pushpakumar’s “twofinger sign” method was done by asking the subject to fully extend the index and middle finger, then wrist and other fingers were asked to flexed and finally the thumb was asked to fully opposed and flexed. 11 all above mentioned tests are based on making the tendon taut by eliciting its weak flexor action and making pl prominent, leading to its recognition visually and by palpation. 9 statistical analysis was done using spss version 21. the frequencies and percentages of unilateral or bilateral pl agenesis were presented with a 95% confidence interval. the association between absence of the palmaris longus, body side and sex were assessed using chi-square test. statistical significance was set at p <0.05. results the study involved 202 subjects. there were 98 males and104 females with age range of 18-22years. out of a total 202 students examined. pl of both sides were present in 155 subjects (76.7%) while 47 (23.3%) had pl agenesis. out of these 47 subjects, bilateral agenesis was found in 16 (7.9%) while 31 (15 %) had unilateral agenesis. on further analysis of unilateral agenesis, 13 (6.4%) had left sided agenesis while18 (8.9%) had right sided agenesis (figure1). figure 1: morphological variation of palmaris longus muscle in study population (n=202). hence, agenesis was more common on the right side as compared to the left, and difference was statistically significant (p =0.05) (table1). overall, male subjects had frequency of agenesis of palmaris longus tendon (unilateral & bilateral combined) of 29 out of 98 (29.5%), while in female subjects, frequency was18 out of 104 (17.3%). the pattern for absence of pl was different in both genders. males had 22(21.5%) unilateral agenesis and only 7(7.1%) had bilateral agenesis. while 9 (8.6%) females had unilateral agenesis and similarly 9 (8.6%) had bilateral agenesis of pl (table1) discussion the palmaris longus (pl) is one of the most variable muscles in the human body and its agenesis among different populations have been reported by various previous studies. 9 pl is clinically important for the surgeons. it is required as a tendon graft for reconstructive surgery including correction of ptosis, lip augmentation, management of facial nerve palsy. 12 it is also used as a tendon transfer for opponensplasty in restoring the intrinsic functions in cases of recurrent median nerve injury. 13 in present study, overall agenesis of pl muscle in both genders was 23.3%. our results are justified by a study conducted on multiracial medical students including chinese, indians and malays at the university of n= 155(76.7%) n= 16(7.9%) n=13(6.4%) n= 18(8.9%) bilateral presence (pl) bilateral agenesis (pl) left agenesis (pl) right agenesis agenesis of palmaris longus muscle j aziz fatm med den college jan-june 2020; vol.2, no 1 6 table1.frequencies of palmaris longus agenesis muscle according to gender and laterality (n=202) palmaris longus muscle gender total (%) (n=202) p value male (%) ( n=98) female (%) (n=104) left agenesis 10 (10.2%) 3 (2.9%) 13 (6.4%) 0.05 * right agenesis 12 (12.2%) 6 (5.8%) 18 (8.9%) bilateral agenesis 7 (7.1%) 9 (8.6%) 16 (7.9%) bilateral presence 69 (70.4%) 86 (82.7%) 155 (76.7%) malaya, malaysia that reported a diversity in the ranges of incidence of absence of pl among various races. aforementioned study has reported a higher incidence of unilateral and bilateral pl absence in medical students from india than any other races. 14 contrary to the current results numerous previous studies reported lower prevalence of 3.4-4.6% in other asian population including japanese and chinese. 11 6.7% of pl agenesis was documented in yoruba ethnic population that is the largest ethnic groups in africa. 11 another malaysian study reported 11.7% of agenesis of pl in malay population. 15 highest prevalence of 50% agenesis of pl was reported in egyptian population, that is highest rates of absence of pl than any other ethnic groups in the world. 16 contradictory to current results lowest percentage of 1.5% was reported in zimbabwean population. 12 large variability in documentation concerning pl agenesis by all abovementioned studies proved that the prevalence of agenesis is ethnically determined. present study found that the unilateral agenesis of pl was more common than bilateral agenesis in our study population (15% vs 7.9%). pl was frequently absent in the right limb in our study participants. contradictory to our findings osonuga et al reported absence of pl in left side that is non dominant hand, on the other hand some researchers have documented bilateral agenesis being more common. 12,13 our findings showed significantly higher frequency of agenesis of palmaris longus in men than in women (29.5 % vs 17.3%). on comparison of laterality of agenesis of pl among the gender, we noted that unilateral agenesis of right-side pl is more common than bilateral pl agenesis in male. in females unilateral and bilateral agenesis was found in equal proportions. our results are not in line with other previous studies that reported frequent absence of pl in females than males. recent past study conducted in kashmir reported prevalence of absence of pl in 12.1% in females and 6.7% in males, furthermore this kashmiri study found that bilateral agenesis was common than unilateral pl agenesis. 17 an indian study also documented higher prevalence of pl agenesis in females as compared to male population (40.2% vs 14.7%) and unilateral being more common than bilateral pl agenesis. 18 results of current study add to the literature and reaffirm the previous studies that the absence of pl depends on race and ethnicity. epidemiological studies on a broader scale should be conducted for evaluation of ethnically based anatomic variation in pl tendon, which has a clinical and surgical importance. limitations: agenesis of pl is only determined by clinical examination rather than by ct or mri. results cannot be generalized to the whole population due to small sample size and single center study. conclusion unilateral agenesis is more common than bilateral agenesis. agenesis of pl is more frequent in males as compared to females. suggestion: to confirm the correct anatomic facts, further studies on wider scale are required. funding source: none. conflicts of interest: none. references 1. dąbrowski k, stankiewicz-jóźwicka h, kowalczyk a, markuszewski m, ciszek b. the sonographic morphology of musculus palmaris longus in humans. folia morphol (warsz).2018;77(3):509-513.doi:10.5603/fm.a2017.0116. 2. longhurst g, stone d, mahony n bilateral reversed palmaris longus muscle: a case report and systematic literature review .surgradiol anat. 2020 mar;42(3):289295. doi: 10.1007/s00276-019-02363-z. review 3. olewnik ł, waśniewska a, polguj m, podgórski m, łabętowicz p, ruzik k, et al morphological variability of the palmaris longus muscle in human fetuses.surg radiol anat.2018 (11):1283-1291. doi:10.1007/s002 76-0182069-2 https://en.wikipedia.org/wiki/malaysia https://www.ncbi.nlm.nih.gov/pubmed/31720753 https://www.ncbi.nlm.nih.gov/pubmed/31720753 https://www.ncbi.nlm.nih.gov/pubmed/30022223 https://www.ncbi.nlm.nih.gov/pubmed/30022223 faiqa haris et al. j aziz fatm med den college jan-june 2020; vol.2, no 1 7 4. olewnik ł, wysiadecki g, polguj m, podgórski m, jezierski h, topol m. anatomical variations of the palmaris longus muscle including its relation to the median nerve a proposal for a new classification. bmc musculoskelet disord. 2017 ;18(1):539. doi:10.1186/s1289 -017-1901-x. 5. kumar n, patil j, swamy rs, shetty sd, abhinitha p, rao mk, et al. presence of multiple tendinous insertions of palmaris longus: a unique variation of a retrogressive muscle. ethiop j health sci. 2014 apr;24(2):175-8. 6. sunil v, rajanna s, gitanjali kj. variation in the insertion of the palmaris longus tendon. singap med j.2015;56:e7 – https://sma.org.sg/uploadedimg/files/smj/5601/5601cr 3.pdf (date of access 9 may2020). 7. mathew aj, sukumaran tt, joseph s versatile but temperamental: a morphological study of palmaris longus in the cadaver. j clin diagn res. 2015 feb;9(2):ac01-3. doi: 10.7860/jcdr/2015/11212.5542. 8. cetin a, genc m, sevil s, coban yk. prevalence of the palmaris longus muscle and its relationship with grip and pinch strength: a study in a turkish pediatric population. hand. hand (n y). 2013;8(2):215-20. doi:10.1007/s11552 013-9509-6. 9. shenoy rm. two new clinical tests for palmaris longus. indian j plast surg. 2018;51(3):321-323. doi:10.4103/ijps. ijps_105_18. 10. dimitriou i, katsourakis a, natsis k, kostretzis l, noussios g palmaris longus muscle's prevalence in different nations and interesting anatomical variations: review of the literature.j clin med res. 2015;7(11):825830.doi:10.14740/jocmr2243w. review. erratum in: j clin med res. 2016 jan;8(1):62. 11. mbaka go, ejiwunmi ab prevalence of palmaris longus absence--a study in the yoruba population.ulster med j. 2009;78(2):90-93. 12. osonugaa , mahama hm, brown aa, osonuga oa, serbeh g, harding an, et al. the prevalence of palmaris longus agenesis among the ghanaian population. asian pac j trop dis. 2012;2(supplement 2):s887-89. 13. ali m. soltani,1 mirna peric,1 cameron s. francis,1 thien-trang j. nguyen,1 linda s. etal. the variation in the absence of the palmaris longus in a multiethnic population of the united states: an epidemiological study. plast surg int.2012;2012:282959.doi:10.11555/2012/2829 59. 14. kassim, n.m., zulkafli, i.s., zamin, r.m. et al. the incidence of agenesis of palmaris longus muscle among multiracial medical students of university malaya, malaysia. indian j surg. 2019. https://doi.org/10.1007/s12 262-019-02026-8 (date of access: 2nd may2020). 15. yong mw, yusof n, rampal l, arumugam m. prevalence of absence of palmaris longus and its association with gender, hand dominance and absence of fds tendon to little finger among malay population. j hand surg asian pac vol. 2017 dec;22(4):484-489. doi:10.1142/s02188104 1750054x. 16. raouf ha, kader ga, jaradat a, dharap a, fadel r, salem ah. frequency of palmaris longus absence and its association with other anatomical variations in the egyptian population. clin anat. 2013 ;26(5):572-7. doi: 10.1002/ca.22186 17. kkhan mj , shafi ms, shoukat a, ahmed ka, azad s, ayub mz et al.prevalence of absence of palmaris longus muscle in kashmiri population. jrmc. 2016; 20(2):124128. 18. sankar kd, bhanu ps, john sp.incidence of agenesis of palmaris longus in the andhra population of india. indian j plast surg.2011;44(1): 134-138. doi: 10.4103/09700358.81448. author’s contribution: dr. quddus ur rehman study design and data collection, manuscript writing, and accountable for research work. dr. usman latif study design and data collection, critically revision of the manuscript and approve the final version. accountable for research work. dr. faiqa haris dr. faiza liaqat data collection, manuscript writing, revision and approval of final version. statistical analysis, interpretation of results, critically revise and approve the manuscript all authors are equally accountable for material provided. received: 10 nov 2019, revised received: 20 dec 2019, accepted: 1 jan, 2020. https://www.ncbi.nlm.nih.gov/pubmed/29258498 https://www.ncbi.nlm.nih.gov/pubmed/29258498 https://www.ncbi.nlm.nih.gov/pubmed/29258498 https://www.ncbi.nlm.nih.gov/pubmed/24795520 https://www.ncbi.nlm.nih.gov/pubmed/24795520 https://www.ncbi.nlm.nih.gov/pubmed/24795520 https://sma.org.sg/uploadedimg/files/smj/5601/5601cr3.pdf https://sma.org.sg/uploadedimg/files/smj/5601/5601cr3.pdf https://www.ncbi.nlm.nih.gov/pubmed/25859436 https://www.ncbi.nlm.nih.gov/pubmed/25859436 https://www.ncbi.nlm.nih.gov/pubmed/25859436 https://www.ncbi.nlm.nih.gov/pubmed/30983734 https://www.ncbi.nlm.nih.gov/pubmed/26491493 https://www.ncbi.nlm.nih.gov/pubmed/26491493 https://www.ncbi.nlm.nih.gov/pubmed/26491493 https://www.ncbi.nlm.nih.gov/pubmed/26668687 https://www.ncbi.nlm.nih.gov/pubmed/26668687 https://www.ncbi.nlm.nih.gov/pubmed/19568443 https://www.ncbi.nlm.nih.gov/pubmed/19568443 https://doi.org/10.1007/s12%20262-019-02026-8 https://doi.org/10.1007/s12%20262-019-02026-8 https://www.ncbi.nlm.nih.gov/pubmed/29117832 https://www.ncbi.nlm.nih.gov/pubmed/29117832 https://www.ncbi.nlm.nih.gov/pubmed/29117832 https://www.ncbi.nlm.nih.gov/pubmed/29117832 https://www.ncbi.nlm.nih.gov/pubmed/23339087 https://www.ncbi.nlm.nih.gov/pubmed/23339087 https://www.ncbi.nlm.nih.gov/pubmed/23339087 https://www.ncbi.nlm.nih.gov/pubmed/21713200 https://www.ncbi.nlm.nih.gov/pubmed/21713200 j aziz fatm med den college july december 2021; vol. 3, no. 2 46 original article impact of consanguinity marriage on developing type 1 diabetes in beta thalassemia children rukhshan khurshid, nafisa fatima, muhammad shahroz hamza, shakil ahmad, iram fayyaz, huma ashraf abstract objective: to find impact of consanguinity marriage on developing diabetes in a group of thalassemia children. methodology: a cross sectional study carried out from october 2016 to june 2017at thalassemia centers of lahore city. one hundred and fifty beta thalassemia major children with age range 4 to 8 years receiving regular blood transfusion were recruited by purposive sampling. structured questionnaires were filled by the consented parents of children. results: among total number of thalassemia patients, the frequency of male was100 and of female was 50. the frequency of male and female diabetic thalassemia children was 25 (25 %) and 25 (50%) respectively. frequency of general consanguinity was 148(98.66%). weak correlation of fasting blood sugar with consanguinity in diabetic thalassemia children was observed. conclusion: consanguinity marriages may have a role on developing diabetes in thalassemia children. keywords: beta thalassemia, consanguinity marriages, diabetes. introduction thalassemias are the known hereditary ailments worldwide. globally, 15 million individuals have the disorder of thalassemia and its incidence is very high in developing countries like pakistan, bangladesh, india and other asian countries, where thalassemic children require regular blood transfusions to withstand life, as this may be reason of overload of iron resulting dysfunction of liver, pancreas etc.1,2 consanguineous marriages (cm) are very common globally especially in pakistan, lebanon, turkey, north america, africa , australia and europe and it is the main reason for increasing the occurrence of the ____________________________________________________________ rukhshan khurshid, msc, ph.d assistant professor, shalamar medical & dental college, lhr nafisa fatima, mbbs,mphil senior demonstrator sheikh zayed hospital post graduate medical institute lhr muhammad shahroz hamza, mbbs senior medical officer , model rhc mustafabad district kasur shakil ahmad, mbbs, mphil associate professor kind edward medical uni, lhr iram fayyaz, mbbs, mphil professor cmh medical college lhr huma ashraf, mbbs, mphil associate professor cmh medical college lhr correspondence: dr. rukhshan khurshid email: rakhshan99@yahoo.com thalassemia. consanguinity is demarcated as marriage between first /second cousins.3 the consanguinity is a complex and multifaceted characteristics with biological and socio cultural debates on its advantages and disadvantage. the negative effects of cm are the late development of multifaceted disease including the diabetes, heart problems, schizophrenia and others as these are heterogeneous etiologically in many of the families.4,5 highly susceptible genes may have an important role in expression of these multifaceted diseases, and if these genes are spread in an autosomal recessive style then consanguinity may be a causative factor.6 in well-chelated thalassemia children the incidence of diabetes was 9% which may increase further from 20 to 30 %, depend on the age and chelation intensity.7 diabetes is more suspected in thalassemia children due to iron-induced toxicity. it is proposed that accumulation of iron in pancreatic beta cells of thalassemia patient may alter glucose tolerance resulting in overt diabetes. however, the actual mechanisms of iron-stimulated diabetes are not known. it is proposed that deficiency of insulin, resistance of insulin, dysfunction of liver and genetic issues may be the reason of developing diabetes in thalassemia patients.8,9 it is experimentally proved that altered fasting blood glucose is seen in subjects having consanguineous marriages and this may increase the risk of developing diabetes in their generation.10 the biological outcome of consanguinity comprises the increased level of homozygosity, which may increase the risk of genetic diseases at the level of population and family.2 regular transfusion of blood raises the chances of endocrinological link diseases like type 1 j aziz fatm med den college july december 2021; vol. 3, no. 2 47 diabetes. iron over load is the main reason of complication of endocrinopathy in patients of thalassemia. in some patients, iron may accumulate in pancreas and may interrupts the function of pancreatic cells that may results diabetes.6 besides consanguinity may have a role to increase the chances of developing diabetes by consolidation of the genetic effects on fasting blood glucose.7 number of studies were carried out to observe the association between consanguinity and genetic conditions /health problems like diabetes, heart disease, mental disorder, immunodeficiency disorders, hypertension, betathalassemia, low birth weight and down syndrome. this proves the role of genetic elements across the complete spectrum of ailments.5 studies showed that many organs like liver, pancreas and others may be effected. however we tried to find out the relationship of consanguinity with type 1 diabetes in thalassemia children which may be an extra burden in the management of health issues in thalassemic children. this study may help the medical experts to plan chelating procedure, and tried to prevent the children to develop diabetes and other complications. study was tried to found the impact of consanguinity marriage on developing diabetes in a group of thalassemia children. methodology a study based on correlation analysis of frequency distribution was carried out from october 2016 to june 2017 at thalassemia centers of lahore city after obtaining ethical approval from the institute (f-39 /nhrc/ admn /irb/). one hundred and fifty beta thalassemia major children with age range 4-8 years receiving regular blood transfusion were included through purposive sampling technique. children with co-existing medical conditions have co morbidity of other chronic disease like cardiac and renal diseases were excluded from the study. a detailed history and physical examination were done. liver size and spleen sizes were noted. questionnaire was filled by consented parents of children. thalassemia major was diagnosed by sign and symptoms and electrophoretic rep ort of hemoglobin. children with no history of diabetes were included in the study. blood samples of all children was drawn after overnight fasting ( 810 hour). estimation of blood glucose was carried out by standard kit using auto analyzer. level of serum insulin was estimated by elisa. homa-ir index was used to calculated insulin resistance (fasting blood sugar x fasting insulin /22.5) and cut off value was taken as 2.27. fasting blood glucose less than 100 mg/dl was taken as indicator of standard glucose tolerance. altered fasting blood was found, when the level of fasting blood glucose is in between of 100 & 126 mg/dl.14 statistical analysis: the data was analyzed by spss version 20. categorical variables were expressed as frequency and percentages. pearson correlation coefficient was used to find the correlation between fasting blood sugar and consanguinity in diabetic thalassemia children. p < 0.05 is taken as significant. results distribution of thalassemia children in relation of consanguinity and progression of diabetes is tabulated as table1. among total number of thalassemia patients, the frequency of male was100 (66.66 %) and of female was 50 (33.3 %). frequency of family history of thalassemia was observed in 70 (46.66 %). table 1: distribution of thalassemia children in relation of consanguinity and progression of diabetes (n=150) characteristics frequency (n) percentages (%) male thalassemia children 100 66.6 female thalassemia children 50 33.3 family history of thalassemia 70 46.66 diabetic male thalassemia children 25 25 diabetic female thalassemia children 25 50 general consanguinity 148 98.66 consanguinity first cousin 2nd cousin 100 48 67 % 33 % consanguinity ratio in male /female 2:1 the frequency of male and female diabetic thalassemia children was 25 (25 %) and 25 (50%) respectively. insulin resistance was more frequently found in female as compared to male diabetic consanguinity marriage & dm in thalassemia children https://www.sciencedirect.com/topics/medicine-and-dentistry/heredity j aziz fatm med den college july december 2021; vol. 3, no. 2 48 weak correlation of fasting blood sugar with consanguinity in diabetic thalassemia male /female children (r = 0.11). thalassemic children (2.9 versus 1.3). frequency of general consanguinity was 148 (98.66%) (table1). frequency of first cousin consanguinity was 100 (67 %) and of 2nd cousin were 48 (33 %). the consanguinity ratio in male / female was 2:1. fasting blood glucose of diabetic thalassemic children was 135.50 ± 10.50 mg/dl. weak correlation of fasting blood sugar with consanguinity in diabetic thalassemia children was observed with r value 0.11 with p value 0.58 (fig1). discussion endocrine complications are the known complications in β-thalassemia and are mostly credited to overload of iron. regular blood transfusion may increase the risk of developing type 1 diabetes, as excess of iron deposition in β cells of pancreas. this iron deposition may decrease the secretion of insulin and results in hyperglycemia.15among total number of thalassemia patients, the frequency of thalassemia in male was greater than female. we agreed with a study who observed that majority of thalassemia patients were males16. however studies found that gender differences in expression profiles of thalassemia patients proposing that females and males are differentially pretentious by the β thalassemia. 17,18 the frequency /percentage of both male/female diabetic thalassemia children were 33%. however a study found 16.1% of thalassemic patients had diabetes.19 another study noted that the incidence of diabetes in thalassemia children was 17.5%.9 frequency of first cousin consanguinity was 100 (67 %) and of 2nd cousin were 48 (33 %). according to an iranian study the incidence of thalassemia is 3.6% and consanguinity based incidence is 0.6%.20 according to some studies the frequency of cousin marriage is 133(74%) and 135 (74%). it is stated that consanguineous marriages possibly play an vital role in the spreading of β-thalassaemia.21,22 a sri lankan study found that consanguinity rate in beta thalassemia patient was 14.5%, in tamil population it was 44 % and 12 % in sinhalese.23 according to our study the frequency of male/ female diabetic thalassemia children was 25 (25%) and 25 (50%) respectively with impaired fasting glucose and insulin resistance. insulin resistance was more in female as compared to male diabetic thalassemic children. according to study carried out in iran, the incidence of diabetes in iranian thalassemic major patients was 9.0 % and estimated degree was 12.60% for thalassemic males and 10.80 % for thalassemic females. in these patients there are high percentages of impaired fasting glucose and glucose tolerance.24 a study also reported that diabetes is link with thalassaemia major. study found that long term blood transfusion may be the reason of impaired fasting glucose and diabetes in thalassemia patients.25 it is proposed that pancreatic iron is a powerful predictor for glucose metabolism and also for cardiac iron and complications. impaired fasting blood glucose, blood glucose tolerance, and diabetes in thalassemic patients is also noted.7,9 weak correlation of fasting blood sugar with consanguinity in diabetic thalassemia children was observed. number of studies observed the incidence of diabetes in thalassemia children. it is proposed that accumulation of iron in pancreas may be a reason of the risk of diabetes depend on the duration of iron overload.9 another study state that there may be role of deficiency of insulin, dysfunction of liver and genetic impact of consanguinity that may start in early.11,19 additionally a study found that due to regular transfusions, pancreatic iron may cause impaired glucose tolerance and overt diabetes.9 limitations: study has no information of iron load, only estimated via the iron take through transfusion. conclusion consanguinity marriages may have a role on developing diabetes in thalassemia children. however, more studies are needed to find the impact of consanguinity marriages on developing diabetes in beta thalassemia children. recommendations: it is suggested that there is a need of awareness of risk of complications of betafigure 1: correlation of fasting blood sugar with consanguinity in diabetic thalassemia children rukhshan khurshid et al j aziz fatm med den college july december 2021; vol. 3, no. 2 49 thalassemia after family marriage via pre-marriage psychotherapy is necessary. funding source: none conflicts of interest: none references 1. hossain, m.s., hasan, m.m., raheem, e. muhammad si, al mosabbir a, petoru m et al. lack of knowledge and misperceptions about thalassaemia among college students in bangladesh: a cross-sectional baseline study. orphanet j rare dis. 2020; 15:54. doi.org/10.1186/s13023-020-1323-y 2. kimita w, petrov ms. iron metabolism and the exocrine pancreas, clinica chimica acta 2020; 511:167-176 doi.org/10.1016/j.cca.2020.10.013. 3. hamamy h. consanguineous marriages: preconception consultation in primary health care settings. j community genet. 2012; 3(3):185-192. doi:10.1007/s12687-011-0072-y 4. hamamy h, antonarakis se, cavalli-sforza ll, temtamy s, romeo g, ten kate lp et al.consanguineous marriages, pearls and perils: geneva international consanguinity workshop report. genet med. 2011; 13:841-847 5. bener a, mohammad rr. global distribution of consanguinity and their impact on complex diseases: genetic disorders from an endogamous population. egypt j med hum genetics2017;18(4):315320doi.org/10.1016/j. ejmhg.2017.01.002. 6. bittles ah, black ml. the impact of consanguinity on neonatal and infant health. early hum. dev. 2010; 86:737– 741. doi: 10.1016/j.earlhumdev.2010.08.003. 7. pepe a, meloni a, rossi g, et al. cardiac complications and diabetes in thalassaemia major: a large historical multicentre study. br j haematol 2013;163:520–527 8. inati a, mohammad han, mansour a, abbas ha. endocrine and bone complications in 𝛽-thalassemia intermedia: current understanding and treatment. bio med res int volume 2015, article id813098,9pageshttp:// dx.doi.org/10.1155/2015/813098 9. pepe a, pistoia l, gamberini mr2, cuccia l, peluso a, messinag et al. the close link of pancreatic iron with glucose metabolism and with cardiac complications in thalassemia major: a large, multicenter observational study. diabetes care 2020; 43(11): 2830-2839.https://doi.org/ 10.2337/dc20-0908 10. shahid a, saeed s, rana s, mahmood s. family history of diabetes and parental consanguinity: important risk for impaired fasting glucose in south east asians. west indian med j. 2012 ;61(3):219-223. doi: 10.7727/wimj.2011.072. 11. bhinder mr, mahmood n, muhammad q, hussain z, muhammad mr et al. consanguinity: a blessing or menace at population level? hum genetics 2019; 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9:5472 doi.org/10.1038/s41598-019-41905 18. nanou a, chrisavgi toumpeki, pavlos fanis, nicoletta bianchi, lucia carmela cosenza, cristina zuccato et al. sex-specific transcriptional profiles identified in βthalassemia patients. haematologica. 2021; 106(4):12071211. doi:10.3324/haematol.2020.248013 19. olivatto gm, teixeiracrs, sisdelli mg, maria lúcia zanetti, silveira rccp gonçalves cv. characterization of thalassemia major and diabetes mellitus patients at a reference center in brazil. hematol, trans and cell ther. 2019; 41 (2):139-144 doi.org/10.1016/j.htct.2018.08.005. 20. khodaei gh, farbod n, saeidi m. frequency of thalassemia in iran and khorasan razavi. int j ped. 2013; 1(1):45-50 21. hamamy h. “consanguineous marriages: preconception consultation in primary health care settings,” j comm gen. 2012; 3(3):185–192 22. khan ms, ahmed m, khan ra, mushtaq n, wasim ullah shah m. consanguinity ratio in b-thalassemia major patients in district bannu. j pak med assoc. 201 ;65(11):1161-1163. 23. premawardhena ap, de silva st, goonatilleke mddc, ediriweera ds, mettananda s, rodrigo bkrp, et al. marriage patterns in sri lanka and the prevalence of parental consanguinity in patients with β-thalassaemia: a crosssectional descriptive analysis. j biosoc sci. 2020l; 52(4):573584. 24. azami m, sharifi a, norozi s, mansouri a, sayehmiri k. prevalence of diabetes, impaired fasting glucose and impaired glucose tolerance in patients with thalassemia major in iran: a meta-analysis study. caspian j intern med. 2017; 8(1):115. 25. bazi a, sharifi-rad j, rostami d, sargazi-aval o, safa a. diabetes mellitus in thalassaemia major patients: a report from the southeast of iran. j clin diagn res. 2017; 11(5):bc01-bc04. doi:10.7860/jcdr/2017/24762.9806 consanguinity marriage & dm in thalassemia children https://care.diabetesjournals.org/content/43/11/2830#aff-2 https://pubmed.ncbi.nlm.nih.gov/?term=shahid+a&cauthor_id=23155976 https://pubmed.ncbi.nlm.nih.gov/?term=saeed+s&cauthor_id=23155976 https://pubmed.ncbi.nlm.nih.gov/?term=rana+s&cauthor_id=23155976 https://pubmed.ncbi.nlm.nih.gov/?term=mahmood+s&cauthor_id=23155976 https://onlinelibrary.wiley.com/action/dosearch?contribauthorstored=bhinder%2c+munir+ahmad https://www.haematologica.org/article/view/9912#author-1 https://www.haematologica.org/article/view/9912#author-2 https://www.haematologica.org/article/view/9912#author-3 https://www.haematologica.org/article/view/9912#author-4 https://www.haematologica.org/article/view/9912#author-4 https://www.haematologica.org/article/view/9912#author-5 https://www.haematologica.org/article/view/9912#author-6 j aziz fatm med den college july december 2021; vol. 3, no. 2 50 author’s contribution: rukhshan khurshid concept, study design, data collection, literature search, analysis, first draft writeup nafisa fatima study design , data collection, literature search, second draft write up muhammad shahroz hamza data analysis, final review, overall supervision shakil ahmad data analysis, revised and approved the article iram fayyaz data analysis, revised and approved the article for intellectual content. huma ashraf: manuscript drafting, data analysis, revised and approved the manuscript. all authors are equally responsible for the validity of the data rukhshan khurshid et al received: 05 aug 20201, revised received: 04 sep 2021, accepted: 13 sep 2020 j aziz fatm med den college january – june 2022; vol. 4, no. 1 18 original article effect of rivaroxaban in stroke prevention in patient with atrial fibrillation due to valvular heart disease waqar shamim, muhammad rizwan, rizwan rasul khan, masood javed, nasir mahmood, kashif nawaz abstract objective: to observe the effect of rivaroxaban in patients with atrial fibrillation due to valvular heart diseases for proper anticoagulation to avoid stroke. methodology: an observational follow up study was carried out in cardiology department of aziz fatimah hospital, faisalabad from february to august 2021. the study included 36 patients of valvular heart disease with atrial fibrillation on warfarin, whose inr was not tested during the last 4 months due to lack of facility nearby. all patients with non-valvular atrial fibrillation were excluded. all patients were given rivaroxaban to replace warfarin. these patients were followed up for 6 months in the opd of the same hospital to observe the end points including stroke and bleeding episodes and ischemic changes on ecg. results: total of 36 patients of mean age and sd of 56±7.00 years were followed up. out of which 20 were male and 16 were female subjects. not a single incident of stroke or bleeding episode or bruises was observed during the 6 months follow up. on echocardiographic examination, none of the patients showed clot in the left atrium. left atrium size and lv ejection fraction remained the same, during next visit. la size 44±5 and 44±6 on 1st and second visit respectively (p value = 0.059) no other ischemic changes found in the ecg of any patient. international normalization ratio (inr) mean and sd was 2.1±0.9, 2.2±0.8, on 1st and 2nd visit of follow up respectively and no significant difference were noted between inr values. conclusion: rivaroxaban can be given safely to the patients with valvular heart disease with atrial fibrillation, particularly in patients who cannot get the inr checked on regular basis. keywords: atrial fibrillation, rivaroxaban, valvular heart disease. introduction atrial fibrillation is one of the most important cause of thrombo-embolic stroke in patients with valvular heart disease.1,2 risk of thrombo-embolism increases dr. waqar shamim mbbs, md professor aziz fatimah medical and dental college, fsd dr. muhammad rizwan mbbs, fcps assistant professor aziz fatimah medical and dental college, fsd dr. rizwan rasul khan mbbs, fcps associate professor aziz fatimah medical and dental college, fsd dr. masood javed mbbs, fcps professor aziz fatimah medical and dental college, fsd dr. nasir mahmood mbbs, fcps associate professor aziz fatimah medical and dental college, fsd dr. kashif nawaz mbbs, fcps senior registrar aziz fatimah medical and dental college, fsd correspondence: dr. waqar shamim email: waqarshamim63@gmail.com in patients who are not taking antithrombotic medicines properly.3,4 effectiveness of treatment to prevent ischemic stroke, warfarin, can be checked by inr.5 despite the use of warfarin, there are higher number of thrombotic strokes in patients with atrial fibrillation, probably due to the failure of checking the inr values on regular basis.6-8 in pakistan, most of the patients living in the villages are either unaware or lack the nearby facility of getting this test done.9,10 therefore, such patients usually get the complications due to the over dosage or under dosage of anticoagulation.11 in this study we aimed to see the effect of rivaroxaban in preventing any thrombo embolic stroke, development of thrombus in the left atrium and assess its safety with regards to bleeding tendency with its use. rivaroxaban is a fast acting, direct factor xa inhibitor that disable the conversion of prothrombin to thrombin. rivaroxaban is already licensed for use in stroke prevention in non-valvular atrial fibrillation, dvt, and pulmonary embolism.12the reason to conduct this study was to evaluate safety and efficacy of rivaroxaban in our population as conventionally used drug, warfarin requires strict monitoring by j aziz fatm med den college january – june 2022; vol. 4, no. 1 19 international normalized ratio (inr) which is not possible mostly in our population due to various reasons. the lack of local published data on the role of rivaroxaban in the prevention of stroke in patients with atrial fibrillation due to valvular heart disease prompted us to carry out the present study methodology an observational follow up study was carried out in cardiology department of aziz fatimah hospital, faisalabad from february to august 2021, after taking the ethical approval from institutional ethical committee with ref.no: iec/1143-21. we recruited 36 consecutive patients of valvular heart disease, particularly mitral stenosis with dilated left atrium reporting to outpatient department and indoor facility of cardiology department. these patients were with age 45 and above, having long standing persistent atrial fibrillation with a heart rate between 80 to120 per minutes. all the patients had been taking warfarin for atleast 4 to 6 months without having any access to the inr test facility nearby were included in this study. in this observational follow up study which included patients whose inr was not tested during the last 4 months. all patients aged less than 45 years of age and non-valvular atrial fibrillation were excluded from the study. enrolled patients were put on oral rivaroxaban 15 mg once daily to replace warfarin. patients were instructed to contact immediately if they experienced any clinical evidence of stroke (symptoms were explained to the patients in details). these patients were then prospectively followed up for the next 6 months. during this follow up period, patients were assessed in the cardiology opd with history, physical examination, ecg, chest x ray and echocardiography after every 3 months. international normalized ratio (inr) was estimated and calculated as a ratio of the patient's pt to a control pt standardized for the potency of the thromboplastin reagent developed by the world health organization (who) using the following formula: inr = patient pt / control pt. reference range for inr value from a score of 2.0 to 3.0 was considered normal.13 electrocardiographic measurements: standard 12 lead electrocardiograms were recorded using a hewlett packard xli page writer (model m1700a) on a paper speed of 25 mm/s using calibration of 0.1 mv/mm. parameters measured manually using electronic calipers (model no. cd-6" cp; mitutoyo, uk ltd). echocardiograms: echocardiography was performed by an experienced cardiologist using toshiba nemio xg. twodimensional, and 2-d guided m-mode recordings of left ventricle (lv) were obtained from the conventional parasternal view with the patient in left semilateral position. short axis and apical views were also obtained to examine the clot or thrombus. lv ejection fraction was estimated using the equation, ef=(edd 3 esd 3 )/edd 3 %. statistical analysis: stat view 5.0 (abacus concepts inc. usa) for windows, a computer statistical package, was used to analyze the data. the data are presented as mean  standard deviation for counts. the kolmogirovsmirnov test was applied to confirm whether data followed the normal distribution. differences in mean values and their significance were calculated using independent student t-tests after stratifying the assumptions. a probability value of less than 0.05 was taken as statistically significant. results total of 36 patients of mean age and sd of 56±7.00 years were followed up. out of which 20 were male and 16 were female subjects. one patient lost the follow up due to his immigration to another country. table 1: basic characteristics of patients (n= 36) characteristics mean±sd age (years) 56±7.00 systolic bp (mmhg) 130±14.00 diastolic bp (mmhg) 80±6.00 heart rate (beats/min) 90±12 lvef in percentages 68±7 lvef= left ventricular ejection fraction bp =blood pressure sd=standard deviation figure 1: international normalized ratio (inr) of patients with atrial fibrillation on rivaroxaban inrinternational normalization ratio 2.04 2.06 2.08 2.1 2.12 2.14 2.16 2.18 2.2 2.22 inr r a ti o visit 1 visit 2 waqar shamim et al j aziz fatm med den college january – june 2022; vol. 4, no. 1 20 discussion warfarin, a vitamin k antagonist is commonly used for prevention of thrombo-embolic phenomenon and stroke in patients with valvular and non-valvular atrial fibrillation.13,14 inr monitoring is most commonly recommended for the patients who are on warfarin. the dose of warfarin is adapted based on inr scores so that it remains in the therapeutic range to prevent thrombosis from subtherapeutic inr or hemorrhagic complications from supratherapeutic inr.13 it is always difficult to titrate the dose of warfarin according to the required levels of inr. despite monitoring and careful dose adjustment, inr values outside the target range are frequently observed.14 now recent researchers are focusing on the rivaroxaban, that has proven efficacy in stroke prevention in non-valvular atrial fibrillation in place of warfarin for stroke prevention in af.15 non vitamin k antagonists (noacs) including rivaroxaban, as a group have been declared to have an edge over conventionally used vitamin k antagonist namely warfarin in several international guidelines.16 this study was conducted to evaluate the outcomes of rivaroxaban prescribed to prevent stroke in patients with valvular heart disease, particularly mitral stenosis with dilated left atrium. we evaluate these for any type of episode of bleeding, bruises or stroke and inr value during the follow up. none of the followed-up patient showed any episode of bleeding, bruises or stroke in current study and inr remain unchanged and within normal range during follow up . on echocardiographic examination, none of the patients showed clot in the la. our results are justified by reporting of various researchers. guimarães et al in their study on brazilian population also found rivaroxaban to be safer and more effective than warfarin. incidence of stroke was delayed by mean 347.5 days in patients on rivaroxaban as compared to mean 340.1 days in patients on warfarin.17 furthermore, deaths from cardiovascular events in patients on rivaroxaban were also less (3.4%) as compared to those on warfarin (5.1%). same conclusion was drawn by barón-esquivias et al in their review article comparing the safety and efficacy of rivaroxaban and warfarin in preventing stroke in patients with non-valvular atrial fibrillation. 18 gregory et al in a review article especially focused on asian population with atrial fibrillation and found all noacs including rivaroxaban to be safe in preventing stroke in patients with atrial fibrillation. 19 all noacs except rivaroxaban had lower hazard ratio in causing hemorrhagic stroke as compared to warfarin. this may be because of higher daily dose of rivaroxaban (20 mg) in this study whereas in our study the daily dose was less (15 mg). jaberi et al20 studied the cost effectiveness of rivaroxaban in iranian population in hospital-based study in city of sheraz and concluded it to be more cost effective as compared to warfarin. being newer molecule in pakistan, there is very limited relevant data available. in a limited study by haider. et al21 while studying rivaroxaban in patients with cerebral venous sinus thrombosis, found it to be safe and effective alternative to warfarin whereas in a similar study conducted at rawalpindi medical college, rawalpindi, pakistan by maqsood. et al found no difference in terms of efficacy between rivaroxaban and warfarin to cause recanalization following cerebral venous sinus thrombosis.22 limitation: no doubt this is a medium sized study, the result cannot be generalized to such patients at large in clinical practice. further research with bigger sample size of such patients with more prolonged follow-up is required in this regard. conclusion rivaroxaban can be given to patients with atrial fibrillation due to valvular heart disease particularly those who do not have access to inr test facility in immediate vicinity. funding source: none conflicts of interest: none references 1. hindricks, gerhard,potpara, tatjana,dagres, nikolaos, et al; (29 august 2020). "2020 esc guidelines for the diagnosis and management of atrial fibrillation developed in collaboration with the european association of cardio-thoracic surgery (eacts)". european heart journal. 2020; 42 (5): 373–498. 2. benjamin ej, blaha mj, chiuve se, cushman m, das sr, deo r, et al; american heart association statistics committee and stroke statistics subcommittee. heart disease and stroke statistics-2017 update: a report from the american heart association. circulation. 2017;135:e146– e603. 3. bai y, wang yl, shantsila a, lip gyh.the global burden of atrial fibrillation and stroke: a systematic review of the clinical epidemiology of atrial fibrillation in asia. chest. 2017;152(4):810820. 4. steinberg ba, piccini jp. anticoagulation in atrial fibrillation. bmj. 2014;348:g2116. doi: 10.1136/bmj.g2116. 5. january ct, wann ls, calkins h, chen ly, cigarroa je, cleveland jc jr, et al. 2019 aha/acc/hrs focused update of the 2014 aha/ acc/hrs guideline for the management of patients with atrial fibrillation: a report of the american college of cardiology/american heart association task force on clinical practice guidelines and the heart rhythm society. j am coll cardiol. 2019;74:104–132. 6. ferguson c, inglis sc, newton pj, middleton s, macdonald ps, davidson pm. atrial fibrillation: stroke prevention in focus. aust crit care. 2014 may;27(2):92-8. doi: 10.1016/j.aucc.2013.08.002. rivaroxaban in valvular af about:blank about:blank about:blank about:blank about:blank about:blank j aziz fatm med den college january – june 2022; vol. 4, no. 1 21 7. alkhouli m, friedman pa. ischemic stroke risk in patients with nonvalvular atrial fibrillation: jacc review topic of the week. j amcollcardiol.2019;74(24):3050-3065.doi: 10. 1016 /j.jacc. 2019. 10.040. 8. wilson d, ambler g, banerjee g, shakeshaft c, cohen h, yousry ta, etal. clinical relevance of microbleeds in stroke (cromis-2) collaborators. early versus late anticoagulation for ischaemic stroke associated with atrial fibrillation: multicentre cohort study. j neurol neurosurg psychiatry. 2019;90(3):320-325. 9. argulian e, conen d, messerli fh. misconceptions and facts about atrial fibrillation. am j med. 2015 sep;128(9):938-42. doi: 10.1016/j.amjmed.2015.02.016. 10. nguyen tn, hilmer sn, cumming rg. review of epidemiology and management of atrial fibrillation in developing countries. int j cardiol. 2013;167(6):2412-20. doi: 10.1016/j.ijcard.2013.01.184. 11. staerk l, sherer ja, ko d, benjamin ej, helm rh. atrial fibrillation: epidemiology, pathophysiology, and clinical outcomes". irc res. 2017;120(9):1501-1517.doi: 10. 1161 /circresaha. 117.309732. 12. amerena jv, walters te, mirzaee s, kalman jm. update on the management of atrial fibrillation. med j aust. 2013;199(9):592-7. doi: 10.5694/mja13.10191. 13. shikdar s, vashisht r, bhattacharya pt. international normalized ratio (inr)]. in: statpearls treasure island (fl): statpearls publishing;2022jan-. availablefrom: https:// www.ncbi. nlm.nih.gov /books/nbk507707/. [cited on 20th jan 2022] 14. lip gyh, keshishian a, li x, hamilton m, masseria c, gupta k, et al. effectiveness and safety of oral anticoagulants among nonvalvular atrial fibrillation patients. stroke. 2018;49: 49(12):2933-2944. doi: 10.1161/strokeaha.118.020232. 15. yu ayx, malo s, svenson lw, wilton sb, hill md. temporal trends in the use and comparative effectiveness of direct oral anticoagulant agents versus warfarin for nonvalvular atrial fibrillation: a canadian population-based study. j am heart assoc. 2017;6: (11):e007129. doi: 10.1161/jaha.117.007129. 16. lip gyh, y, gue, j. zhang, t.-f. chao, h. calkins and t. potpara.. stroke prevention in atrial fibrillation. trends in cardiovascular medicine. https://doi.org/10.1016/j.tcm.2021.10.001.cited on 19jan22https://doi.org/10.1016/j.tcm.2021.10.001 17. guimarães hp, lopes rd, de barros e silva pgm, liporace il, sampaio ro, tarasoutchi f,et al., 2020. rivaroxaban in patients with atrial fibrillation and a bioprosthetic mitral valve. n engl j med. 2020;383(22):2117-2126. doi: 10.1056/nejmoa2029603. 18. barón-esquivias g, marín f, sanmartín fernandez m.. rivaroxaban in patients with atrial fibrillation: from rocket af to everyday practice. expert rev cardiovasc ther. 2017;(5):403-413. doi: 10.1080/14779072.2017.1309293. 19. lip gy, wang kl, chiang ce. non-vitamin k antagonist oral anticoagulants (noacs) for stroke prevention in asian patients with atrial fibrillation: time for a reappraisal. int j cardiol. 2015;180:246254. doi: 10.1016/j.ijcard.2014.11.182. 20. jaberi n, kavosi z, hooshmandi e, moradi n, keshavarz k, borhanihaghighi a the study of cost-effectiveness of rivaroxaban versus warfarin in patients with atrial fibrillation who developed ischemic stroke. stroke res treat.;2021:5534873.doi: 10.1155/2021/5534873. 21. haider sa, batool h, mukhtar s, iqbal a, luqman s, tariq a. role of rivaroxaban in patients with cerebral venous thrombosis. pakistan journal of neurological surgery. 2021;25(3):414419.http://pakjns.org/index.php/pjns/article/view/595 22. maqsood m, imran hasan khan m, yameen m, aziz ahmed k, hussain n, hussain s. use of oral rivaroxaban in cerebral venous thrombosis. j drug assess. 2020 ;10(1):1-6.doi:10.1080/21556660. 2020.1838769. authors’ contribution: dr. waqar shamim concept, literature search, data collection, analysis, first draft writeup. dr. m. rizwan literature search, data collection, second draft write up. dr. rizwan rasul khan study concept and design, analysis, final review, overall supervision. dr. masood javed literature search, study design & concept, data interpretation dr. nasir mahmood literature search, study design & concept, data interpretation dr. kashif nawaz literature search, data collection, drafting all authors are equally accountable for research work and integrity. date of submission: 23-09-2021 revised received: 17-01-2022 accepted: 19-012022 waqar shamim et al about:blank about:blank about:blank about:blank about:blank about:blank http://www.ncbi/ https://doi.org/10.1016/j.tcm.2021.10.001.cited https://doi.org/10.1016/j.tcm.2021.10.001 https://pubmed.ncbi.nlm.nih.gov/34531970/ https://pubmed.ncbi.nlm.nih.gov/34531970/ https://pubmed.ncbi.nlm.nih.gov/34531970/ https://pubmed.ncbi.nlm.nih.gov/34531970/ http://pakjns.org/index.php/pjns/article/view/595 https://pubmed.ncbi.nlm.nih.gov/33391859/ https://pubmed.ncbi.nlm.nih.gov/33391859/ j aziz fatm med den college july december 2021; vol. 3, no. 2 61 short communication vitamin d and vitamin d receptor in female infertility nida farooqui, qurat-ul-ain maha, mussarat ashraf, arfa azhar, farrukh jehan, rehana rehman abstract objective: to investigate the possible association of serum and follicular fluids(ff) vitamin d levels with reproductive outcomes after assisted reproductive techniques (art). secondly, to detect vitamin d receptors (vdr) in serum and follicular fluid (ff) of ovarian follicle and explore its relationship with vitamin d levels as well as reproductive outcomes. methodology: this study was conducted on may 2019 in aga khan hospital, karachi, pakistan. a total of 8 infertile female subjects were conveniently recruited. serum was collected and follicular fluid(ff) was obtained by transvaginal-guided follicular puncture; 34 hours after intramuscular administration of human chorionic gonadotrophin (hcg). vitamin d and vdr was assessed in serum as well as in ff by paired sample t-test. results: females 2 out of 8 acquired clinical pregnancy, whereas 3 had pre-clinical abortion or no pregnancy. vitamin d and vdr were detected highest in those female patients that acquired pregnancy in comparison to the pre-clinical abortion or non-pregnant ones (p value<0.007). serum vdr did not show any significant results in all groups conclusion: vitamin d in serum and ff and vitamin d receptor in serum and ff were associated with number of oocytes. high levels of vdr in ff observed in clinical pregnancy group proved our hypothesis that the presence of vdr in ff is a contributing factor for successful conception after art success. keywords: assisted reproductive technique, female infertility, follicular fluid, vitamin d, vitamin d receptor introduction vitamin d (vd) is a known fat solubilizing vitamin, playing a pivotal role in the homeostasis of phosphorus and calcium, thus maintaining healthy teeth and bones. vd also fortifies the body against ailments such as; diabetes, obesity, cancer, cardiovascular disease and even in infertility.1 vitamin d deficiency (vdd) is also observed to be associated with many female reproductive maladies including. ____________________________________________________________ nida farooqui, msc senior research assistant aga khan university khi qurat-ul-ain maha 3rd year medical student aga khan university khi mussarat ashraf, msc,mphil senior technologist aga khan university khi dr. arfa azhar, mbbs, mphil senior instructor aga khan university khi farrukh jehan, msc,mphil senior embryologist australian concept infertility medical centre khi dr. rehana rehman, mbbs,phd associate professor & vice chair research & graduate studies aga khan university khi correspondence: dr. rehana rehman email: rehana.rehman@aku.edu endometriosis, polycystic ovarian syndrome (pcos), gestational diabetes, and bacterial vaginosis etc.2 according to a study in oklahoma, vdd is highly seen in women who are diagnosed with pcos.3 another study in pakistan, have also reported the prevalence of vdd in women with pcos.4 due to the role of vd seen in the process of steroidogenesis and in the activity of aromatase, it can be a possibility that vd effects the quantity and quality of oocytes and hence the pregnancy by increasing the production of estradiol.5,6 in a study conducted in california, 1192 women of reproductive ages were recruited and among them it was observed that the infertile women had low vd levels; 68.6% had <32 ng/ml whereas, 22.2% had <20 ng/ml levels.7 vitamin d receptor (vdr) is the transcriptional protein located in the target cell’s nucleus and various tissues (uterus, endometrium, ovaries and placenta) and helps in the biological actions of vd.8,9 after vd binds with its receptor, it regulates homeobox protein hox-a10 (hoxa10) gene activity, immune response of endometrium and reduces t-cell activity.10,11 according to previous a study, it was observed that females having high levels of vd in follicular fluid (ff) and serum have a higher chance of conceiving following ivf, hence vd levels in ff independently can determine ivf outcome.12 with this background, we came across with following research questions; is there a role of ff vitamin d with pregnancy j aziz fatm med den college july december 2021; vol. 3, no. 2 62 outcome? what is the importance of vdr in acquiring pregnancy outcome? so, the objective of our study was to find an association between ff and serum vitamin d and vdr, with pregnancy outcome after in vitro fertilization. methodology this study was conducted in aga khan hospital, karachi pakistan on may 2019, after acquiring approval from the institutional ethical review committee(aku-bbs-2019-0557-5582).using conv enient sampling methodology, eight infertile females with unexplained cause of infertility undergoing assisted reproductive technique (art) were recruited for this study after obtaining a written informed consent, they were expected to fulfill the criteria of primary infertility, and were between the ages of 18-40 years from infertility medical centre, karachi, pakistan. women more than 40 years, having bmi more than 30 kg/m2, on oral contraceptive pills and hormonal treatments or practicing any contraceptive measures and women with serious general health status was excluded. their ovaries were stimulated by exogenous gonadotropin (follicle stimulating hormone; fsh) from day 5 of the cycle and then given human chorionic gonadotropin (100,000) injections when at least 2-3 follicles reached maturity (a diameter of 18 mm). transvaginal-guided follicular puncture and aspiration of ff was performed under general anesthesia 35 ± 1 hour after administration of hcg. both serum and ff samples were collected on the same day, after centrifuge at the speed of 3000xg for 15 minutes, supernatant was collected and stored at -80oc. vdr levels in serum and ff were observed by using commercially available enzyme linked immunosorbent assay kit (cat. no: sea475hu, cloud-clone corp) with a detection range of 0.625 – 40 ng/ml. the analytical sensitivity was less than 0.225 ng/ml, and intra-inter assay coefficient of variation (cv) was <10% and 12% respectively. whereas, vd levels in serum and ff observed by human, 1,25-dihyroxy vitamin d elisa kit (cat#95503), with an intra-inter assay coefficient of variation (cv) of 2.7% and 4.3%, respectively. the lowest limit of detection was 2.8 ng/ml. statistical analysis: data was analyzed using ibm spss version 23. the distribution of quantitative variables was computed by their means and standard error of mean (se) and assessed by spearman’s rank correlation test. paired sample t-test was used to compare means. statistical significance was set at p<0.05. results a total of 8 infertile female subjected were recruited for this study. their demographic and biochemical data are mentioned in table 1. table 2: correlation of serum and follicular fluid vitamin d with study parameters factors correlation coefficient/ r value p-value serum vd with vd in ff 0.972 0.001* serum vd with serum vdr 0.713 0.047* serum vd with ff vdr 0.959 0.0001* vd in ff with serum vdr 0.586 0.126 vd in ff with ff vdr 0.947 0.001 * serum vd with oocytes 0.857 0.007* serum vdr with oocytes 0.488 0.220 ff vd with oocytes 0.890 0.003* ff vdr with oocytes 0.883 0.004 * serum vd with bmi -0.690 0.05 * ff vd with bmi -0.689 0.05* serum vdr with bmi -0.723 0.043* ff vdr with bmi -0.764 0.027* ff vdr with vd 0.571 0.139 *significant p-value of ≤0.05 via spearman’s rank correlation test table 2 represents, correlation in serum and ff levels of vd and vdr with study parameters. a positive significant correlation was observed in serum vd with different parameters such as vd in ff, serum vdr, vdr in ff and number of oocytes. a negative correlation of bmi with vd and vdr in both serum and ff was observed (table 2). out of the 8 patients, 2 females acquired clinical pregnancy (25%), 3 female patients (37.5%) had preclinical abortion and 3 did not get pregnant. those females who conceived had the highest vd in ff (p value<0.002) levels as compared to the pre-clinical abortion and non-pregnant females (p value<0.247). vdr in ff were highest in clinical pregnancy (p table 1: demographic, biochemical characteristics of infertile females (n=8) factors mean ± se age (years) 34.38 ± 1.73 bmi (kg/m2) 21.38 ± 0.86 serum vitamin d (ng/ml) 28.45 ± 1.27 vitamin d follicular fluid (ng/ml) 29.84± 1.26 vdr in follicular fluid (ng/ml) 27.32 ± 7.48 serum vdr (ng/ml) 0.1 ± 0.09 vd and vdr in female infertility j aziz fatm med den college july december 2021; vol. 3, no. 2 63 value<0.002). however, serum vdr did not show any significant results in all the groups (figure 1). figure 1 demonstrates the detected levels of vitamin d in serum, vitamin d in follicular fluid and vitamin d receptor in follicular fluid of infertile female undergoing assisted reproductive technique (n=8) subjects *significant at p value ≤0.05 by paired sample t-test discussion we observed high vitamin d levels in serum and ff of females with successful conceptions which is supported by our previous study, in which we documented that vitamin d helped in acquiring optimum endometrial thickness necessary for successful implantation during ics.13 and also in another study, higher serum and ff level of vitamin d was found concomitant with better pregnancy rates after intracytoplasmic sperm injection(icsi).14 furthermore, farzadi et al. observed that vitamin d though did not affect number and quality of oocytes yet improved success rate after ivf(11). vitamin d levels in ff showed no correlation with oocyte quality, fertilization rate, and reproductive outcome.15 a number of biological function of vitamin d is facilitated by vdrl.16our findings showed a significant relation between vitamin d and vdr. although, vdr is present in follicular fluid but its association with vitamin d may not be functional which give rise to infertility in the females. in a previous animal study, the role of vdr has been reported through the effect on availability of calcium ions in null mutant female mice.17 current study major finding was the positive significance relation between vdr in serum collected from blood and vdr in ff of infertile females indicating that increase of vdr in serum increases significantly in follicular fluid. a negative significant relation between bmi and vitamin d and vdr levels of the subjects indicates that as their bmi increases their vd and vdr levels significantly decreases. significant differences was observed in vdr and vitamin d of ff in a study with females having polycystic ovarian syndrome and overweight patients.18 in order to improve vitamin d and vdr, infertile females should be asked to reduce their bmi as this will help in increasing vdr and vitamin d in ff and hence chance of conception. hence, predominance of vitamin d in serum and ff helped infertile females in acquiring clinical pregnancy after icsi. however, negative levels of serum vdr indicates that vitamin d receptors cannot be found in serum, but can be detected in the follicular fluid playing its role in assisting vitamin d of infertile females to achieve their pregnancy, this novel approach of detecting vdr in follicular fluid is taken for the first time in our study. nonetheless, proper randomized clinical trials with larger sample size are required to accomplish more convincing results about the auspicious role of vitamin d and vdr in the management of female assisted reproduction. limitations: we did not calculate sample size and conducted our pilot study on a very small sample. conclusion vitamin d in serum and ff and vitamin d receptor in serum and ff were associated with number of oocytes. high levels of vdr in ff observed in clinical pregnancy group proved our hypothesis that the presence of vdr in ff is a contributing factor for successful conception after art success. conflict of interest: none funding source: none acknowledgments we would like to acknowledge our vendor shariq, who provided us the elisa kits for vd and vdr. this work was supported by the research module funds provided by department of biological & biomedical sciences, aga khan university karachi. references 1. s. basit .vitamin d in health and disease: a literature review, bjbs, 70:4, 161172, doi: 10.1080/09674845.2013.11669951 2. caroline k. kramer, balakumar swaminathan, anthony j. hanley, philip w. connelly, mathew sermer, bernard zinman, et al. vitamin d and parathyroid hormone status in pregnancy: effect on insulin sensitivity, β-cell fuction, and gestational diabetes mellitus, j clin endocrinol metab. 2014:99(12);45064513, https://doi.org/10.1210/jc.20142341. 3. rainer d, davis e, peck j, hansen kr, craig lb. vitamin d deficiency and time to pregnancy in women with polycystic ovary syndrome. fertil. steril. 2012;1;97(3):s22. doi: https://doi.org/10.1016/j.fertnstert.2012.01.053 rehana rehman et al https://doi.org/10.1080/09674845.2013.11669951 https://doi.org/10.1210/jc.20142341 https://doi.org/10.1016/j.fertnstert.2012.01.053 j aziz fatm med den college july december 2021; vol. 3, no. 2 64 4. azhar a, abid f, rehman r. polycystic ovary syndrome, subfertility and vitamin d deficiency. j coll physicians surgpak2020;30(5):545546.doi:https://doi.org/10.29271/jcpsp.20 20.5.545 5. parikh g, varadinova m, suwandhi p, araki t, rosenwaks z, poretsky l, et al. vitamin d regulates steroidogenesis and insulin-like growth factor binding protein-1 (igfbp-1) production in human ovarian cells. horm. metab. res. 2010;42(10):754-7. doi: 10.1055/s-0030-1262837 6. liu nq, hewison m. vitamin d, the placenta and pregnancy.archbiochembiophys.20121;523(1):3747.doi:https:/ /doi.org/10.1016/j.abb.2011.11.018 7. ranjana h. role of vitamin d in infertility. j public health policy plann. 2017; 1:20. 8. shahbazi m, jeddi-tehrani m, zareie m, salek-moghaddam a, akhondi mm, bahmanpoor m, et al. expression profiling of vitamin d receptor in placenta, decidua and ovary of pregnant mice.placenta.2011;32(9):65764.doi:https://doi.org/10.1016/j.pl acenta.2011.06.013 9. shahrokhi sz, ghaffari f, kazerouni f. role of vitamin d in female reproduction. clinica chimica acta. 2016; 455:33-8. doi: https://doi.org/10.1016/j.cca.2015.12.040 10. lerchbaum e, obermayer-pietsch b. vitamin d and fertility: a systematic review. eur j endocrinol.2012;166(5):76578. doi: 10.1530/eje-11-0984 11. farzadi l, bidgoli hk, ghojazadeh m, bahrami z, fattahi a, latifi z, et al. correlation between follicular fluid 25-oh vitamin d and assisted reproductive outcomes iran j reprod med. 2015;13(6):361. 12. ozkan s, jindal s, greenseid k, shu j, zeitlian g, hickmon c, et al. replete vitamin d stores predict reproductive success following in vitro fertilization. fertil steril. 2010 ;94(4):13149.doi: 10.1016/j.fertnstert.2009.05.019 13. abdullah uh, lalani s, syed f, arif s, rehman r. association of vitamin d with outcome after intra cytoplasmic sperm injection. j matern fetal neonatal med. 2017;30(1):117-20. doi: 10.3109/14767058.2016.1163680 14. majeed i, seiman mo, qasim bj, faisal gg. the effect of serum and follicular fluid vitamin d on intracytoplasmic sperm injection outcome. jidmr. 2020;13(2):791-5. 15. patrycja skowrońska, michał kunicki, ewa pastuszek, lucyna konieczna, tomasz bączek & krzysztof łukaszuk follicular fatsoluble vitamins as markers of oocyte competency, syst biol reprodmed.2020;66:2, 112121, doi: 10.1080/19396368.2020.1 718244 16. lerchbaum e, obermayer-pietsch b. mechanisms in endoc rinology: vitamin d and fertility: a systematic review . eur j endocrinol. 2012;166:765–778. doi: 10.1530/eje-11-0984 17. johnson le, deluca hf. vitamin d receptor null mutant mice fed high levels of calcium are fertile. j nutr. 2001;131(6):178791. doi: 10.1093/jn/131.6.1787 18. aghadavod e, mollaei h, nouri m, hamishehkar h. evaluation of relationship between body mass index with vitamin d receptor gene expression and vitamin d levels of follicular fluid in overweight patients with polycystic ovarysyndrome.intjfertilsteril.2017;11(2): received: 10 mar 20201, revised received: 20 may 2021, accepted: 30 may 2021 author’s contribution: nida farooqui data collection, literature search, draft writeup. qurat-ul-ain maha, literature search, manuscript write up and approved it mussarat ashraf study concept and design, analysis, integration of results, result writeup arfa azhar data collection statistical analysis proved the manuscript. farrukh jehan concept, data analysis & approved the manuscript. dr. rehana rehman concept, study design, result write up & approved manuscript. all authors are equally accountable for research work and integrity vd and vdr in female infertility https://doi.org/10.29271/jcpsp.2020.5.545 https://doi.org/10.29271/jcpsp.2020.5.545 https://doi.org/10.1016/j.abb.2011.11.018 https://doi.org/10.1016/j.abb.2011.11.018 https://doi.org/10.1016/j.placenta.2011.06.013 https://doi.org/10.1016/j.placenta.2011.06.013 https://doi.org/10.1016/j.cca.2015.12.040 https://doi.org/10.1530/eje-11-0984 https://doi.org/10.1016/j.fertnstert.2009.05.019 https://doi.org/10.3109/14767058.2016.1163680 https://doi.org/10.1080/19396368.2020.1718244 https://doi.org/10.1080/19396368.2020.1718244 https://doi.org/10.1530/eje-11-0984 https://doi.org/10.1093/jn/131.6.1787 j aziz fatm med den college july – dec 2021; vol. 3, no. 2 26 original article comparison of enzyme-linked immunosorbent assay and chemiluminescence immunoassay for thyroid stimulating hormone analysis in tertiary care hospital lahore nusrat alavi, aneela khawaja, maliha asif, asma ejaz, abeer, faiqa arshad abstract objective: to compare enzyme-linked immunosorbent assay and chemiluminescence immunoassay for thyroid stimulating hormone analysis in human serum. methodology: this cross-sectional study conducted from 17th march till 13th june. in punjab rangers teaching hospital, lahore after approval from institutional review board. random samples from both genders, between 18-70 years of age were included. haemolysed, lipemic or icteric specimens were excluded. the sera were assayed for thyroid stimulating hormone (tsh) by enzyme-linked immunosorbent assay (elisa) and chemiluminescence immunoassay (clia). data was analyzed by spss 24. results: a total of one hundred and ninety-eight serum samples were processed by elisa and clia in all the samples, with more females as compared to males (1:1.3). elisa technique identified 134 subjects as euthyroid, 40 hypothyroid and 24 hyperthyroid, while 122 euthyroid, 48 hypothyroid and 28 hyperthyroid subjects by clia. thyroid stimulating hormone (tsh) levels reference range was taken 0.4-4.5mu/l according to american thyroid association. mean ± sd of tsh was 1.45 ± 0.79; 12.27 ± 11.03 and 0.23 ± 0.17 mu/l respectively by elisa whereas clia indicated mean ± sd to be 1.93 ± 0.936, 16.04 ± 14.68 and 0.393 ± 0.375 mu/l respectively for euthyroid, hypothyroid and hyperthyroid. correlation of coefficient (r2 =0.89) was found significantly positive between both methods. there was a significant difference in hypothyroid and euthyroid groups. conclusion: tsh assay by clia has shown a wider range of functionality, throughout and borderline cases were identified better as compared to elisa. turn-around-time (tat) decreased, physician satisfaction increased and indirectly benefitting patient treatment and prognosis. keywords: chemiluminescence immunoassay, enzyme-linked immunosorbent assay, thyroid stimulating hormone. introduction thyroid hormones critically regulate the growth and metabolic key pathways of different organs as well as __________________________________________ dr.nusrat alavi mbbs, m phil associate professor of pathology rahbar medical & dental college, lhr dr.aneela khawaja mbbs, m phil assistant professor of pathology rahbar medical & dental college, lhr dr.maliha asif mbbs, mphil assistant professor of pathology rahbar medical & dental college, lhr dr.asma ejaz mbbs, mphil assistant professor of pathology, rahbar medical & dental college, lhr dr.abeer mbbs, fcps assistant professor of pathology, rahbar medical & dental college, lhr dr.faiqa arshad mphil, phd scholar, assistant professor of pathology. gujranwala medical college, gujranwala correspondence: dr.nusrat alavi email: nusratpinky@hotmail.com energy homeostasis. worldwide, 300 million people suffer from abnormal thyroid functioning. the most prevalent abnormality of it is the elevation of thyroidstimulating hormone labelled as hypothyroidism, while hyperthyroidism, showing decreased levels of tsh, is less common.1 the modern advancement in technology has categorized the enzyme linked immunosorbent assay into 3rd generation assay. tsh monitoring by enzyme-linked immunosorbent assay (elisa) in very low and very high level of frank hyperthyroidism and hypothyroidism is very benefi cial in grouping subjects according to expression of tsh level.2 elisa is a popular analytic procedure that applies a solid stage enzyme immunoassay (eia) to identify the presence of a specific element, usually an antigen, in a serum sample. in elisa, antigens from the test specimen adjoined to a surface are treated with specific antibody; and enzyme substrate is added as a final step. end point reaction is color change in the substrate producing a detectable signal.3 keeping in mind the benefits, of 4th generation assays, mailto:nusratpinky@hotmail.com j aziz fatm med den college july – dec 2021; vol. 3, no. 2 27 chemiluminescence immunoassay (clia) is widely used as a reliable, sensitive, specific, automated method which measures the immune complexes formed as a result of antigen-antibody reaction by using labelled antibodies. substrate was added to these intact immune complexes producing light signal. the intensity of light (measured as reactive light units, rlu) helps to quantify the labelled complexes. this assay significantly promotes detection of sub-minimal level of active substances in clinical diagnosis and treatment prognosis.4 in third world countries, there is a lack of reliable comparative searches between both techniques. the patients were undergoing over or under treatment and have to bear the brunt of discrepant results produced by different techniques.5,6 the primary aim of our study is to compare values of tsh assessed by both enzyme-linked immunosorbent assay and chemiluminescence immunoassay in a tertiary care setting. methodology this cross-sectional study was conducted in pathology laboratory at punjab rangers teaching hospital, lahore from 17th march till 13th june 2021. after taking ethical approval from institutional review board with irb reference number 07/2021. a total of 198 whole blood samples of both genders, between 18-70 years of age were selected randomly and included in the study. haemolysed, lipemic and icteric specimens were excluded from the study. blood collected in serum separator tubes was centrifuged at 2500 rpm for 15 minutes at room temperature to obtain serum. the separated serum was aliquoted in 2 fresh micro-centrifuged tubes and stored at -20oc. samples were tested simultaneously for tsh by both elisa and clia techniques. both methods were calibrated and controls were run.6 reference range to categorize the patients with thyroid disease was 0.4-4.5mu/l. the quantitative measurement of tsh was done by elisa and clia. monoclonal antibodies coated on elisa strips were directed against serum tsh, which reacts with the two antibodies simultaneously. this sandwich complex is immobilized to the well, and incubated for an hour and excess antibodies are removed by washing the wells. after 15 minutes, stop solution was added and the end product of colored solution was measured by elisa reader set at 450nm.3 the standard for clia technique works as sandwich technique. its principle is to employ monoclonal antibodies specifically directed against human tsh. antibodies labelled with ruthenium complex, which consists of chimeric construct from human and mouse specific components. this test was performed on the fully automated roche cobase 411 analyzer using clia, instructions of training manual were carefully followed. eighty six tests /hour were performed. the total duration of assay was eighteen minutes. two-point calibration curve and master curve presented through the reagent barcode or e-barcode particularly supports the outcomes. statistical analysis: data was analyzed by spss 24.0. continuous variables were expressed as mean ± sd. mean tsh was compared by independent t-test. pvalue ≤ 0.05 was considered as significant. coefficient of correlation was applied between elisa and clia for euthyroid, hypothyroid and hyperthyroid tsh levels. results a total of one hundred and ninety-eight serum samples were processed. table 1 shows comparison of tsh status by elisa and clia in all the samples, with more females as compared to males (1:1.3). tsh assay by both techniques identified 134 and 122 subjects as euthyroid by elisa and clia, respectively. similarly, elisa identified 40 subjects as hypothyroid while 48 were found hypothyroid by clia, on the basis of reference value 0.4-4.5mu/l. the difference was highly significant in hypothyroid and euthyroid subjects. table 1: comparison of thyroid stimulating hormone by elisa and clia (n=198). tsh= thyroid stimulating hormone; elisa= enzyme linked immunosorbent assay; clia= chemiluminescence immunoassay. euthyroid* range was identified in 134 and 122 subjects respectively, by elisa and clia p-value ≤ 0.05 taken as significant. in table 2, the difference of mean cases with similar diagnosis is shown that 37 hypothyroid samples when tested by elisa fall in 4.8-44mu/l, while these same samples by clia gave results from 4.58-38mu/l. shifting of 24 subjects from (134, in table 1) euthyroid by elisa to either hypothyroid or hyperthyroid groups; and 12 subjects from (122, in table 1) euthyroid by clia to other groups. tsh reference 0.4-4.5mu/l elisa clia p-value n 198 mean±sd n 198 mean ±sd hypothyroid 40 12.27±11.03 48 16.04±14.68 <.0005 euthyroid* 134 1.45± 0.79 122 1.93± .936 <.0005 hyperthyroid 24 0.23± 0.17 28 0.393±0.375 0.127 comparison of elisa & clia for tsh j aziz fatm med den college july – dec 2021; vol. 3, no. 2 28 similarly, the difference of hyperthyroid samples (22, as in table 2) was shown by 2 subjects and 6 subjects by elisa (24 as given in table 1) and clia (28 as in table 1), respectively. p-value was highly significant in hypothyroid and euthyroid subjects, while insignificant in hyperthyroid samples. correlation of coefficient (r2=0.89) was positive between both methods (figure 1) elisa* and clia* range of tsh level in n=169 subject discussion thyroid disorders are the commonest endocrine disorders throughout the world including pakistan.7 for diagnosis and management of thyroid diseases, thyroid function test is the most frequently advised endocrine investigation.7 the guiding principles of american thyroid association and american association of clinical endocrinologists serum tsh measurements has recommended as a primary screening test to diagnose most types of hypothyroidism & hyperthyroidism.8 tsh secretion is exquisitely sensitive to minor increase, as well as decreases in serum free t4. abnormal tsh levels are detected earlier during developing the course of hypothyroidism and hyperthyroidism even before free t4 abnormalities become detectable. 8,9 although thyroid disorders are not a life threatening disorder, but if it is not diagnosed timely and remained untreated, it may develop into life threatening disorders like cancer. moreover, thyroid gland malfunctioning will greatly affect various functions of many other body parts which depend on the hormonal secretion of thyroid hormones for performing their normal functions.10 in our study the patients were divided into three groups according to serum tsh levels i.e., euthyroid, hypothyroid and hyperthyroid. our results indicate significant difference in tsh levels measured by elisa and clia for euthyroid, hypothyroid subjects, however the difference was insignificant by both methods for hyperthyroid subjects. same results are documented within pakistan by ejaz et al and internationally by santosh et al. 10,3 in our study, thyroid diseases were found to be more prevalent (56%) in females compared to males. similar findings are reported locally by naz et al and shah et al11,12 and internationally by paczkowska et al.13 in our study, 169 subjects gave same results by both methods with highly significant difference in hypothyroid and euthyroid subjects. statistically, all the data was analyzed for coefficient of correlation and it displayed a significant coefficient of correlation (r2=0.8598) as documented locally by naz et al and foreign researcher hamed et al. 11, 14 in present study two methods, elisa and clia were compared for determination of tsh. the comparison of both methods shows clia exhibit better and higher sensitivity as revealed by higgins et al, with wider range (0.005-100.0mu/l) as compared to elisa figure1: the coefficient of correlation between elisa and clia (n=198) (0.09-40.0 mu/l).15 the reason for this discrepancy could be technique based, errors in pipetting and washing step, fluctuation in instrument handling. other disadvantages of elisa are its laborious techniques with high incidence of false positive and negative results and antibody instability as shown in research by pramila et al.16 in our set up, the clinician’s feedback was considered regarding discrepancy of results and delayed turnaround time prompted the decision to up-grade the diagnostics with advanced 4th generation autoanalyzer. present study clearly indicates that chemiluminescence has better analytical sensitivity than elisa, which can differentiate between normal and subnormal tsh levels as shown by the work done in our region by shah et al and in neighboring countries by higgins et al and jiang et al. 17, 18,15 further studies on a broader scale will yield better results for understanding the importance of diagnostic accuracy of various techniques for thyroid function tests for accurate diagnoses of thyroid disorders. y = 0.8966x + 0.8276 r² = 0.8598 0 5 10 15 20 25 0 10 20 30 c li a elisa table 2: difference in values of serum tsh by two methods(n=169) tsh reference 0.4-4.5mu/l n 169 elisa* mean ± sd clia* mean ± sd hypothyroid 37 4.8-44 11.9± 10.64 4.58-38 15.11± 14.73 euthyroid 110 0.4-3.7 1.44±0.79 0.56-4.2 1.90 ± 0.92 hyperthyroid 22 .009-.36 0.174 ±0.17 .006-.39 0.145 ± 0.12 nusrat alavi et al j aziz fatm med den college july – dec 2021; vol. 3, no. 2 29 conclusion tsh assay by clia has shown a wider range of functionality, throughout and borderline cases were identified better as compared to elisa. turn-aroundtime (tat) decreased, physician satisfaction increased and indirectly benefitting patient treatment and prognosis. conflict of interest: none funding source: whole project was self-funded. acknowledgment: jamil ahmad, sharjeel ahmad are highly acknowledged for compiling data and results compilation. references 1. taylor pn, eligar v, muller i, scholz a, dayan c, okosieme o. combination thyroid hormone replacement; knowns and unknowns. front endocrinol 2019, 22 (10): 706 doi: 10.3389/fendo.2019.00706 2. silvestre ra lafuente aa, jiménez-mendiguchía l, garcía-cano a, lópez rr, garcía-izquierdo b, et al. comparison of three methods for determining anti-thyrotropin receptor antibodies (trab) for diagnosis of graves’ disease: a clinical validation. adv lab med 2021; 2(2): 221-227. doi.org/10.1515/almed-2021-0015. 3. santhosh v, gurulakshmi g, khadeja a, gomathi m. the diurnal variation of thyroid hormones in individuals attending tertiary care hospital, kanchipuram district. biomedical pharmacolj.2020;13(4):17291735. https://dx.doi.org/10.13005/bpj/2 047. 4. xiao q, xu c. research progress on chemiluminescence immunoassay combined with novel technologies. trac trends analyticchem.2020;124:115780https://doi.org/10.1016/j.trac.2019.1 15780 5. mirjanic-azaric b, jerin a, radic z. thyroid stimulating hormone values of clinical decisions of hypothyroidism measurement by three different automated immunoassays. scandinavian j clin laboratory invest. 2020;80(2):151-155. 6. sultana i, alam jm, ali hh, noureen s. reproducibility, repeatability and precision analysis of thyroid function tests (tft) on two, separately operated-lrs integrated roche cobas e411 iecl analyzers. chem res j. 2020; 5(2):151-156 7. yousaf m, shah j, jan mr. frequency of thyroid dysfunctions in general population of peshawar city and its association with serum alanine transaminase level. isra med j. 2017;9(2):84-87 8. garber jr, cobin rh,gharibh,hennessey jv, klein i, mechanick j, et al. thyroid dysfunction: hypothyroidism, thyrotoxicosis, and thyroid function testsfree accessclinical practice guidelines for hypothyroidism in adults: cosponsored by the american association of clinical endocrinologists and the american thyroid association. thyroidvol. 2012 ;22(12):12000-1235.https/:doi:.org /10.1089/thy.2012.0205 9. attaullah s, haq bs,mairman muska m. thyroid dysfunction in khyber pakhtunkhwa, pakistan. pak j med sci. 2016; 32(1): 111– 115.doi: 10.12669/pjms.321.8476. 10. ejaz m, kumar p, thakur m, bachani p, naz s, lal k, shahid w, shahid s, jahangir m, rizwan a. comparison of lipid profile in patients with and without subclinical hypothyroidism .cureus.2021;13(8)e17301.doi: 10.7759/cureus.17301. 11. naz n, rizvi s, sadiq z. assessment of thyroid hormone levels and thyroid disorders: a case study from gujranwala, pakistan. pak j pharmaceutical sci. 2017; 30(4):1245-49. 12. shah n, ursani tj, shah na, raza hm. prevalence and manifestations of hypothyroidism among population of hyderabad, sindh, pakistan. pure appl biol (pab). 2021; 10(3):668-675. http://dx.doi.org/10.19045/bspab.2021.100076. 13. paczkowska k, otlewska a, loska o, kolačkov k, bolanowski m, daroszewski j. laboratory interference in the thyroid function test. endocrinol pol.2020;71(6):55160.doi:10.5603/ep. a2020.0079. 14. hamed a, nmr n, alhalabi n, tayfour r, latifeh y. prevalence of depression in group of hypothyroid patients and its relationship with the level of hypothyroidism. biomed res. 2021; 32(2):1-7. 15. jiang l, du j, wu w, fang j, wang j, ding j. sex differences in subclinical hypothyroidism and associations with metabolic risk factors: a health examination-based study in mainland china. bmcendocrdisord.2020;20(1):18.https://doi.org/10.1186/s12902020-00586-5. 16. pramila k, gopinath p, shanthi k m, divya m. analytical sensitivity of tsh assays by elisa and elfa. nation j basic med sci. 2016; 6 (4): 157-162. 17. shah n, ursani tj, shah na, raza hm. 17. assessment of association between hypothyroidism and hypertension among females of hyderabad, sindh, pakistan. pure appl biol (pab). 2021; 10(3):744-50. 18. higgins v, patel k, kulasingam v, beriault dr, rutledge ac, selvaratnam r. analytical performance evaluation of thyroidstimulating hormone receptor antibody (trab) immunoassays. clin bio chem .2020;86:5660 .https://doi.org /10.1016 /j.clin biochem.2020.08.007 authors’ contribution: dr. nusrat alavi conception of study design, acquisition, analysis and interpretation of data. dr. aneela khawaja drafting and methodology, data interpretation. dr. maliha asif drafting of intellectual content. dr. asma ejaz drafting the research work and critical revision. dr. abeer sheikh analysis and interpretation of data for work. dr. faiqa arshad analysis, acquisition and interpretation of data. all authors participated in study design and writing manuscript and agree to be accountable for accuracy, integrity of all aspects of the work. received: 17 aug 2021, revised received: 10 oct 2021, accepted: 12 oct 2021 comparison of elisa & clia for tsh https://dx.doi.org/10.3389%2ffendo.2019.00706 https://dx.doi.org/10.13005/bpj/2047 https://dx.doi.org/10.13005/bpj/2047 https://doi.org/10.1016/j.trac.2019.115780 https://doi.org/10.1016/j.trac.2019.115780 https://www.liebertpub.com/doi/10.1089/thy.2012.0205 https://www.liebertpub.com/doi/10.1089/thy.2012.0205 https://www.liebertpub.com/journal/thy https://www.liebertpub.com/journal/thy https://doi.org/10.1089/thy.2012.0205 https://www.ncbi.nlm.nih.gov/pubmed/?term=attaullah%20s%5bauthor%5d&cauthor=true&cauthor_uid=27022356 https://www.ncbi.nlm.nih.gov/pubmed/?term=haq%20bs%5bauthor%5d&cauthor=true&cauthor_uid=27022356 https://www.ncbi.nlm.nih.gov/pubmed/?term=muska%20m%5bauthor%5d&cauthor=true&cauthor_uid=27022356 https://www.ncbi.nlm.nih.gov/pmc/articles/pmc4795848/ https://dx.doi.org/10.12669%2fpjms.321.8476 http://dx.doi.org/10.19045/bspab.2021.100076 https://doi.org/10.1186/s12902-020-00586-5 https://doi.org/10.1186/s12902-020-00586-5 j aziz fatm med den college july – dec 2021; vol. 3, no. 2 35 original article spectrum of electroencephalographic findings in seizures under 6 months aged infants at a tertiary care hospital lubna riaz, waqas shafique, fouzia ishaq, neelam faryad, muhammad ali sheikh, naveed shahzad abstract objectives: to determine the spectrum of electroencephalographic findings in epilepsy of infants under 6 months of age methodology it was a cross-sectional study conducted in the pediatrics department, at shaikh zayed hospital, lahore from may 2018 till april 2019. one hundred and forty-two infants aged one to six months of both genders which were newly diagnosed having first episode of seizures recruited by non-probability purposive sampling. infants with no seizures, any central nervous system abnormalities like meningomyelocele, spina bifida, encephalocele, microcephaly and already taking antiepileptic drugs were excluded. patient’s demographic characteristics, seizure pattern and eeg record was obtained on performa. frequencies and percentages were calculated. results: the mean age of infant patients was 3.18±1.90 months (1-6 months). of the 142 infant patients, 97 (68%) were male and 45 (32%) females with positive family history in 42 (30%) patients. epilepsy pattern revealed 101 (71.1%) presented with generalized seizures while 23 (16.2%) had focal seizures. only 1 (0.7%) child suffered from epilepsy syndromes while seventeen (12%) had unclassified seizures. eeg reporting showed 41 (29%) had abnormal tracing. of these, 23 (16%) patients had abnormal focal while 15 (11%) had abnormal generalized frequency and only 3 (2%) were with undetermined reporting. normal eeg was seen in 101 (71%) patients. conclusion: almost one third of patients with epilepsy had abnormal eeg findings so antiepileptic therapy selection must be tailored on individual basis, with special focus on patient’s history and clinical presentation. keywords: epilepsy, electroencephalogram, generalized and focal seizure. introduction epilepsy is a chronic brain condition in which recurrent fits affect cognitive, psychological, neurobiological, and social function.1 there are recurrent and unprovoked seizures which may be generalized or focal associated with loss of conscious ___________________________________________________________ dr. lubna riaz, fcps, mcps, assistant professor, shaikh zayed hospital, lhr dr.waqas shafique, mbbs shaikh zayed hospital, lhr dr. fouzia ishaq, mbbs, fcps professor allied hospital, fsd dr. neelam faryad, mbbs, fcps medical officer sheikh zayed hospital, lhr dr. muhammad ali sheikh, mbbs, fcps professor shaikh zayed hospital, lhr dr. naveed shahzad medical officer shaikh zayed hospital, lhr correspondence to: dr. lubna riaz email: lubnariaz15@gmail.com -ness and bowel, bladder dysfunction. different studies revealed variable incidence of epilepsy worldwide.2 epilepsy affects 0.5%-1% of the children, incidence varies from high income to low middle income countries .3 in bangladesh, it is estimated to be 8.2/1000 (95% ci 3.4-13.0) in children aged <18 years 4 whereas pakistan showed up to 9.99 / 1000 population.5 the electroencephalogram (eeg) is the procedure for detecting brain waves which showed electrical activity of the brain using leads made up of metallic electrodes which records different types of lines/waves on paper.6 there are four types of eeg waves: alpha, beta, theta, and delta. frequency of alpha waves is 9-11cycles per second which are present in the awake and in resting states of the brain. beta waves are of 14 to 80 cycles per second which are predominant in increased mental activity. the frequency of theta waves are 4 to 7 cycles per second, most prominent in children and abnormally present in the excessive form during encephalopathy and degenerative brain diseases of children. delta waves are of 3.5 cycles per second which are present in deep sleep, organic brain diseases, comatose patient, and j aziz fatm med den college july – dec 2021; vol. 3, no. 2 36 severe brain damage.7 we can also diagnose different forms of encephalitis and vasculitis.8 about 50% of the children undergo eeg to diagnose epilepsy but 10% of epilepsy patients never show abnormal discharge and 2-5% have abnormal centro-temporal discharges which are sometimes diagnosed as epilepsy. to rule out these false positive and negative results, video eeg and 24 hour eeg recording should be preferred but these are expensive and time consuming procedures.9 according to the eeg, epilepsy is divided into two classes by the “international classification of epileptic syndromes and epilepsies”. the first one is partial or focal versus systemic, and idiopathic versus cryptogenic or symptomatic.5another classification done by ilae seizure classification shows three types of seizures. one is generalized which involves both hemispheres. sometimes some or all the parts of both hemispheres show abnormal discharges of high voltage on both sides. focal seizures refer to the one side of the brain. on eeg which appears in the form of high amplitude waves of a specific area. epileptic syndrome on the basis of clinical history, abnormal neck movements slam sign, abnormal twitching of eyes, guttering sounds/noises, fits associated with cyanosis and pallor. undetermined is another form of seizures in which no specific areas are involved and on eeg the findings are consistent with generalized or focal.10 rationale of this study was to determine the clinical patterns of epilepsy in infants from first to six months of life and their eeg findings as there is paucity of literature and published data on this aspect in infants in pakistan. the aim of this study was to determine the spectrum of eeg in infants under six months of age having seizures to diagnose and manage them properly in tertiary care centers. methodology it was a cross-sectional study conducted in the pediatrics medicine department, shaikh zayed hospital, lahore and sir ganga ram hospital, lahore from august, 2018 till july 2019. total of 142 cases was included by using 95% confidence level and 8% margin of error with an expected frequency of abnormalities 37.84%.1 infants under 6 months age of both genders which were newly diagnosed having first episode of seizures recruited by non-probability purposive sampling. patients with no seizures, any central nervous system abnormalities like meningo myelocele, spina bifida, encephalocele, microcephaly and already taking antiepileptic drugs were excluded. patients with dysmorphism suggestive of a syndrome or history of congenital heart disease, metabolic disorders or sepsis were also excluded in this study. after approval by the hospital ethical committee (f.39/nhrc/irb-430) and written inform consent from parents, the data was collected through a prestructured questionnaire. demography of study participants like age, gender, socioeconomic status and education level of parents as well as family history of epilepsy was recorded. classification was done as generalized, focal (with preserved or impaired awareness secondary generalized), epileptic syndrome and undetermined. epilepsy was labelled in a patient with any of the following conditions, at least two or more unprovoked seizures occurring 24 hours apart or one unprovoked seizure with either second such seizure. epileptic syndrome was labelled as one or more specific seizure types at specific age of onset with specific eeg changes and prognosis.10 in order to record eeg, electrodes were placed according to the transverse and longitudinal montages with 10–20 systems. the patient was in a supine position on bed and relaxed. paper speed was 30 mm/second with the time constant of 1 second. fifteen minutes awake and 5 minutes sleep recording was taken. photic and hyperventilation activation was recorded for younger infant’s syrup chloral hydrate given orally and sleep recording was taken. a code was given by a number and a ‘blind examiner’ (one who recorded eeg without examining the patient) interpreted the report. we classify eeg as normal, abnormal focal, generalized and undetermined. statistical analysis: data was entered and analyzed by using spss 23. frequencies and percentages were expressed for qualitative variables like gender, types of epilepsy and eeg reporting. quantitative variables like age were presented in mean±sd. proportions are compared by chi-square. p value <0.05 is considered as significant results total 142 cases were enrolled in the study according to selection criteria. the age range was one to six months with mean±sd of age as 3.18±1.90 months. out of 142 cases, 97 (68%) were male and 45 (32%) were female, 42 (30%) cases had family history of epilepsy positive while 100 (70%) had no such history (see table no. 1). when patients were classified according to pattern of seizures, 101 (71.1%) had generalized seizures, 23 (16.2%) had focal partial seizures, 1 (0.7%) had epileptic syndrome and 17 (12.0%) had unclassified seizures (table no. 2). upon eeg reporting, there were 23 (16%) patients who had eeg findings in infants with seizures j aziz fatm med den college july – dec 2021; vol. 3, no. 2 37 abnormal focal reporting while 119 (84%) had no abnormal focal reporting of eeg, 16 (11%) patients had abnormal generalized frequency and 126 (89%) patients had no abnormal generalized frequency and 101 (71%) patients had normal eeg reporting while only 41 (29%) patients had abnormal reporting of the table 1: demographics of patients with epilepsy (n =142) parameters frequency of patient (%age) n =142 (100%) age (in months) 1 – 2 76 (53%) 3-4 18 (13%) 5-6 48 (34%) sex male 97 (68%) female 45 (32%) family history of epilepsy yes 42 (30%) no 100 (70%) table 2: pattern of clinical seizures presentation (n=142) seizure types frequency of patient (%age) generalized seizures 101 (71.1%) focal seizures 23 (16.2%) epileptic syndrome 1 (0.7%) unclassified seizures 17 (12.0%) total 142 (100%) table 3: stratified for clinical pattern of epilepsy with eeg findings (n=142) eeg reporting yes no abnormal focal (high amplitude sharp waves at any region of unilateral hemisphere) 23 (16%) 119 (84%) abnormal generalized (abnormal high amplitude short waves appeared in both hemispheres mostly at the temporoparietal region) 16 (11%) 126 (89%) undetermined (finding consistent with hypsarrhythmia abnormal interictal high amplitude waves and a background of irregular spikes, burst suppression pattern of abnormal waves and predominant delta and theta waves) 3 (2%) 139 (98%) normal 101 (71%) 41(29%) p value 0.666 proportions are compared by chi-square. p value <0.05 is considered as significant. eeg and only 3 (2%) patients had undetermined reporting of eeg and 139 (98%) children had no undetermined eeg reporting in our study (table no. 3).data was stratified for clinical patterns of epilepsy with eeg findings which have insignificant (p value > 0.05) that is 0.666.(table no. 3) fig 1. focal interictal epileptic discharges with suppression over left hemisphere. fig 2. abnormal eeg due/ interracial epileptiform discharges and suppression of background. fig 3. disturbed background with multifocal spike and generalized burst of spike and wave activity followed by electro decremental responses and suppression is suggestive of modified hypsarrhythmia. lubna riaz et al j aziz fatm med den college july – dec 2021; vol. 3, no. 2 38 fig 4. generalized burst of 3hz spike and wave activity of high voltage lasting about 8-10 seconds with normal background (absence seizure). discussion the misdiagnosis rate of epilepsy is very high as compared to other diseases so in order to diagnose it, eeg findings must be reported. proper history of abnormal movements, altered levels of consciousness with detailed neurological examinations are essential for the diagnosis of epilepsy but to confirm these diagnosis, eeg is very important. but on the other hand normal eeg recording does not exclude epilepsy as shown in previous studies that about 10% of epileptic patients never show abnormal discharges on eeg. at the same time abnormal eeg occurred in non-epileptic patients.9 an epileptic syndrome diagnosis is based on specific seizures types at specific age of onset and specific prognosis. by diagnosing epilepsy, management and prognosis are better defined.12 in this study, the mean age of patients was 3.18±1.90 months. half of these were between 12 months of age. a study conducted by ma khalily showed the children with mean age of 5.58±3.46 years were noted with clinical seizures.5 in our study, epilepsy was dominant in males compared to females (2.1:1). this is in agreement with rajper et al. 9 in this study, 71% patients were with generalized epilepsy followed by focal (16.2%) and unclassified seizures (12%). in the study conducted by ma khalily there were 56.8% patients having generalized, 23.5% focal, and syndromic epilepsy in 4.9% of patients which are comparable to our study.5 in another study mostly patients had unclassified seizure (61.2%) found followed by generalized seizure (29.5%) and partial seizure (9%). the current study showed almost one third patients with epilepsy had abnormal eeg findings. similar results have also been reported by ostwal who observed low yield of abnormal eeg (19% and 32.2% respectively).13 other studies showed that eeg abnormality was seen in more than 50% of patients.10,14 abnormal generalized epileptiform discharge was seen in 11% of our respondents. a study by joshi revealed abnormal eeg in 43.3% with generalized epilepsy diagnosed on eeg in 26.21%15. limitations of the study: limitation of the study is that sample size was small and under six months infants were included, and it was done only in two centers so we further recommend that further similar studies should be conducted in different settings with different protocols and include different age groups. conclusion almost one third of patients with epilepsy had abnormal eeg. it is a simple and relatively inexpensive test that should still be used in patients to support the diagnosis of epilepsy. there is no standard operative protocol for the treatment of epilepsy, we can tailor management according to history and clinical condition of the patient. eeg may be helpful in choosing appropriate antiepileptic drugs to minimize adverse effects and drug interactions, thereby improving patient care. disclaimer: none source of funding: none conflict of interest: none acknowledgment: mohammad raahim ahsan, araiz naji, mohammadayaan siddiqui, arqam ahsan and arham ahsan for support and help in research work. references 1. mikati ma, tchapyjnikov d. seizures in childhood. in: kliegman rm, st. geme jw, blum nj, shah ss, tasker rc, wilson km, editors. nelson textbook of pediatrics. 21sted. new york: elsevier saunders, 2020: 3086-3092. 2. seguti fl, pallhares d, ferreira sv, gava m, marasciulo ac. epilepsia e previdência social: a decisão médico-pericial. revista brasileira de saúde ocupacional 2012;37(126-127). 3. aaberg km, gunnes n, bakken ij, lund søraas c, berntsen a, magnus p et al. incidence and prevalence of childhood epilepsy: a nationwide cohort study. pediatrics. 2017 ;139 (5): e201639 08. doi: 10.1542/peds.2016-3908-3918. 4. mohammad qd, saha n, alam b, hoque sa. prevalence of epilepsy in bangladesh: results from a national household survey. epilepsia open 2020; doi: 10.1002/epi4.12430. 5. khalily m. [internet]. cureus.com. 2021 [cited 15 august 2021].availablefrom:https://www.cureus.com/articles/60943spectrum-of-electroencephalography-findings-in-newlydiagnosed epilepsy.pdf eeg findings in infants with seizures https://www.researchgate.net/scientific-contributions/quazi-deen-mohammad-2117924566 https://www.researchgate.net/profile/narayan-saha-3 https://www.researchgate.net/scientific-contributions/badrul-alam-2179148418 https://www.researchgate.net/profile/seikh-hoque https://www.researchgate.net/journal/epilepsia-open-2470-9239 https://www.researchgate.net/deref/http%3a%2f%2fdx.doi.org%2f10.1002%2fepi4.12430 j aziz fatm med den college july – dec 2021; vol. 3, no. 2 39 6. eeg (electroencephalogram) mayo clinic [internet]. mayo clinic.org. 2020 [cited 15 august 2021]. available from: https: //www.mayoclinic.org/testsprocedures/eeg/about/pac-20393875 7. klein k, hamer h. non-invasive eeg evaluation in epilepsy diagnosis [internet]. taylor & francis. 2015 [cited 15 august 2021]. available from: https://www.tandfonline.com/doi/full /10.1586/14737175.2015.1025382?scroll=top &needaccess=true 8. benbadis sr, beniczky s, bertram e, maciver s, moshé sl. the role of eeg in patients with suspected epilepsy. epileptic disord 2020; 22: 143-155. 9. rajper s, mukhtiar k, baloch f, ibrahim s, memon a. spectrum of electroencephalogram finding in children with newly diagnosed epilepsy –an experience at a tertiary care hospital. [internet]. ecommons@aku. 2019 [cited 15 august2021]. available:https://ecommons.aku.edu/pjns/vol14/iss2/4/ 10. fisher rs, the 2017 ilae seizure classification. presented at the american epilepsy society annual meeting, december 2016 11. bhagat r. clinical pattern of epilepsy and their electroencepha logram findings. j neurol neurophysiol 2015; 6 (335-336): 2. 12. tatum wo, rubboli g, kaplan pw et al. clinical utility of eeg in diagnosing and monitoring epilepsy in adults. clin neuro physiol. 2018; 129(5):1056-1082 13. ostwal p, dabadghao v. spectrum of electroencephalographic abnormalities in a cohort of patients from a teaching tertiary care hospital in western india. med j patil univ 2016;9:51. 14. hussain me, khan am, islam n, mian f, azam b, chowdhury rn. different types of epilepsy based on clinical and electro encephalographic (eeg) findings: experience at referral neuro science hospital in bangladesh. j national inst neuro sciences bangladesh 2017; 3(1): 3-6. 15. joshi s, shakya r. a study on eeg findings: an experience from tertiary care centre of nepal. j psychiatrists’ association of nepal 2016;5 (1):32-36. 16. rosenow f, klein km, hamer hm,. non-invasive eeg evalua tion in eilepsy diagnosis. expert rev neurother 2015;15:425-444 17. joyce yw, jurriaan mp, monisha g, darcy k, mustafa s, hope n. clinical electroencephalographic biomarker for impending epilepsy in asymptomatic tuberous sclerosis complex infants. pediatric neurol 2016;54; 29-34. 18. owolabi lf, sale s, owolabi sd, nalado a, umar m, taura aa. electroencephalography abnormalities in generalized epilepsy and their predictors: a multicenter experience. ann afr med 2018;17(2): 64-69. author’s contribution: dr. lubna riaz conceived idea, manuscript, writing, statistical analysis and final review and approval of manuscript dr. waqas shafique study design, data collection and review and approved manuscript. dr. neelam faryad study design, data collection and review and approved manuscript. dr. fouzia ishaq statistical analysis, data interpretation and final approval. dr. naveed shahzad statistical analysis, data interpretation and final approval. dr. m. ali sheikh result interpretation, writ up of results review and approved the manuscript. all authors are equally accountable for research work and integrity received: 05 july 2021, revised received: 28 aug 2021, accepted: 30 aug 2021 lubna riaz et al j aziz fatm med den college july – december 2022, vol. 4. no. 2 8 original article color vision outcome after phacoemulsification with intraocular lens implant in patients with diabetes mellitus nimra gul, iqra iqbal, amna farooq abstract objective: to determine the impaired color function in pseudophakic background diabetic retinopathy patient methodology: after the ethical approval from the university of faisalabad under ethical approval number tuf/dean//2019/39 the cross-sectional study was conducted in the ophthalmology department of madina teaching hospital faisalabad which is associated hospital of the the university of faisalabad. 58 volunteers of both gender and age ranging between 35-75 years were studied through non-probability convenient sampling technique. duration of study was september 2018 to february 2019. visual acuity was tested from logmar at a 4-meter distance. color vision was tested by conventional farnsworth d15 test, along with slit-lamp and +70d lens to evaluate retinopathy severity, after proper consent of the patient. the test was performed after taking complete ocular, medical, surgical and drug history. each pseudophakic eye was tested monocular and each subject was tested thrice. results: results were analyzed using spss version 22. significant association was seen between the color vision in pseudophakic diabetic patient with background retinopathy (p<0.05), using pearson chisquare. color vision by conventional d-15 showed mean of ±2.17 and standard error of ±1.05. while pseudophakic group showed mean of ±1.05 and standard error of ± 0.116. conclusion: there is color defect in pseudophakic diabetic with background retinopathy. the dyschromatopsia is more in the blue axis. color vision defect (cvd) seen more in uncontrolled diabetic than controlled. color vision defect (cvd) increases with the course of retinopathy. color vision checking must be made an integral part of examination specifically in diabetic retinopathy patient. keywords: color vision, cataract, diabetes mellitus, diabetic retinopathy, phacoemulsification, intra ocular lens implant. introduction diabetes mellitus (dm) is an important health problem that induces severe complications. worldwide more than 285 million people are affected by diabetes mellitus.1a ocular problems of diabetes mellitus are progressive and rapidly becoming the world’s most major cause of morbidity.2 subjects with diabetes mellitus are at risk of developing lens opacities and cataract with visual at earlier age as compare to subjects without diabetes.1 cataracts and diabetic retinopathy (dr) are the leading causes of acquired blindness worldwide. 3 nimra gul od; mphil the university of faisalabad iqra iqbal bsop; mphil superior university, faisalabad amna farooq bsen, mphil government college university correspondence: nimra gul e-mail: nimra.gul@tuf.edu.pk phacoemulsification with iol implant for cataracts caused by diabetes mellitus. surgical procedure for vision troubling cataracts caused by diabetes also increases the course of retinopathy for diabetics causing further difficulties.1 it was evident that cataract extraction may possibly lead to a breakdown of the blood-retinal barrier and the blood-aqueous barrier and enhanced intraocular inflammatory response, all of which may result in the occurrence of dr in patients with diabetes.3 regarding vision function, previous studies have shown that contrast sensitivity, impaired color vision (icv), multifocal visually evoked potential (mfvep), and multifocal electroretinogram (mferg) are affected by diabetes, both with and without dr.4 recent past study reported that 50% of the patients in the early treatment diabetic retinopathy study had icv with abnormal hue discrimination. color vision testing provides an adequate and precise method through which j aziz fatm med den college july – december 2022, vol. 4. no. 2 9 nimra gul et al damage to the retina can be measure. color vision is diagnostic tool of determine retinopathy severity.2 much of the color vision loss and increase in frequency of blue–yellow defects with age is attributable to changes in the color and clarity of the ocular media, and in particular, the lens of the eye.4 conflicting results has been reported by previous studies concerning the association of color visual impairment after phacoemulsification for cataracts in retinopathy. some researcher found more icv in pseudophakic patients’, on the other hand some demonstrated that older pseudophakic patients’ color vision resembles that of younger observers.4 diabetes induced microangiopathy leads to diabetic retinopathy (dr), cataract, glaucoma, nephropathy, and neuropathy.3 the risk of retinopathy increases with the duration of diabetes. factors that further increase the risk include: poorly controlled diabetes, high blood pressure, high cholesterol levels, and family history of severe diabetic retinopathy.4diabetics have a higher incidence of visual function alterations depending on the severity of disease. the color vision defect often precedes the onset of retinopathy.5 advancing age, macular edema, diabetic retinopathy or neovascularization contribute in icv that may progress with progression of diabetic retinopathy.6decline in color vision frequently produces changes in clinical measures like visual acuity.6 presence of maculopathy and the increased macular thickness in retinopathy may the results in deterioration of color vision and mostly tritan-like defect are common.7 outcome after cataract surgery was reported to be worse in diabetic patients especially in those with diabetic retinopathy.8 a high glucose concentration in the body also leads to the formation of cataract as the ocular complication by glycosylation and have been associated with impaired color vision (icv).9 icv could affect daily routine activities including driving, education, occupation, discrimination, health and personal safety. that all will ultimately, would impact on their social role and quality of life. 9 there is limited studies that assess the color vision after phacoemulsification with iol diabetic retinopathy. the aim of this study was to determine the assess color function in pseudophakic background diabetic retinopathy patient. methodology after the ethical approval from the university of faisalabad under ethical approval number tuf/dean//2019/39 the cross-sectional study was conducted in the ophthalmology department of madina teaching hospital faisalabad which is associated hospital of the “the university of faisalabad (tuf)”. a sample of 58 patients both male and female was taken, using non-probability convenient sampling technique. duration of study was september 2018 to february 2019. best corrected v/a at least 6/12 was taken. all pseudophakic diabetic patients with background retinopathy were included. both type 1 and type 2 diabetes were taken with age limit 30-75 years and reliable systemic mental approach. while, any previous laser treatment, any ocular condition likely to change color vision like glaucoma or macular degeneration, any systemic disease other than diabetes, iop above normal ranges, posterior capsule opacities (pco), significant macular edema, retinopathy classification done using icdr classification pre-proliferative retinopathy and proliferative retinopathy were excluded. during measurement with conventional d15, subjects were instructed to arrange 15 caps on the basis of hue, which were placed randomly on the white background while sitting at a testing distance of 50cm from caps, in a wellilluminated room. this test was performed both monocularly and binocularly and each subject was tested thrice. slit-lamp and +70d lens were used to evaluate retinopathy severity after proper consent of the patient. the analysis was done by entering whole data into the software of spss version 20. association between color vision defect and pseudophakic diabetic patient with background retinopathy was checked using pearson chi-square for the association. research was done after proper approval from ethical committee of institution results the study was included 58 subjects consisting of 20 patients in group 1 (age 35 to 55 years) in j aziz fatm med den college july – december 2022, vol. 4. no. 2 10 color vision outcome & phacoemulsification in dm which there was 16 females and 4 males and group 2 (age 56 to 75 years) consist of total 38 patients in whom there were 22 males and 16 females. trichromatic defect distribution was found by calculating the frequency out of total 58 subjects. the most present color defect was blue with percentage 61% while for red-green it was 10.2%. color vision by conventional d-15 showed mean of ±2.17 and standard error of ±1.05. while pseudophakic group showed mean of ±1.05 and standard error of ± 0.116. chi_square test was used to determine significance level between color-vision defect and pseudophakic diabetic with background retinopathy which showed p value 0.05 which is significant. this shows color vision decreases as diabetes gets sever. patients having retinopathy found to have defected color vision in all threeaxis red, green and blue. color defect was found more in blue-axis in background retinopathy patients rather red-green. figure 1 depicts population with normal color vision, protanomalous, deuteranomalous, and tritanomalous while the pseudophakic diabetic with background retinopathy with blue color for its presence and red for absence of retinopathy. figure 1: bar graph showing color vision in pseudophakic background diabetic retinopathy age wise distribution of diabetes includes group 1: 35-55 years contain 7 normal 3 type i diabetes and 10 type ii diabetic subjects. group 2: 56-75 years contain 14 normal, 10 type i and 14 type ii diabetic subjects. figure 2 shows population in terms of percentage with non-diabetic in blue color as 36.21%, type1 diabetic with green color as 22.41% and type-2 diabetic in red color as 41.38% respectively. it shows that type 2 is more prevalent than type 1, where insufficient insulin is present in body to meet the needs of glucose metabolism figure 2: pie chart of the frequency of the type of diabetes. color defect increases as course of diabetes increases. a tritanomalous as utmost prevalent color defect out of all color defects among pseudophakic population. red-green color defects found mostly to be of genetic cause than acquired so clinically percentage found to be less than blue in pseudophakic diabetics with retinopathy. figure 3 shows distribution of color defect. figure 3: pie chart of the frequency of color vision defects discussion diabetic retinopathy (dr) remains the leading cause of legal blindness and moderate visual impairment and impaired color vision (icv), among patients with diabetes. it was hypothesized by the previous studies that the formation of new vessels may not adequately supply oxygen for the metabolic needs of the photoreceptors, resulting in death of photoreceptors and hence affecting color vision.10 in this present study the main objective is to evaluate the color vision in pseudophakic diabetic with background retinopathy in age group 30-75. 8 4 1 8 2 2 5 28 0 5 10 15 20 25 30 normal protonomalous deutranomalous tritanomalous f re q u e n cy pseudophakic non diabetic diabetic pseudophakic with background retinopathy j aziz fatm med den college july – december 2022, vol. 4. no. 2 11 nimra gul et al total 58 subjects were examine divided into two groups group 1 containing 30-55 with 20 observations and group 2 containing 56-75 years of age with 38 observations. a total of 26 males and 32 females both with type1 and type2 diabetes studied. subjects were categorized as non-diabetic (n=21) type1 diabetic (n=13) and type2 diabetic (n= 24). type 2 diabetes with 40.68% was more prevalent than type1 with 22.03%. out of 58 subject’s female having diabetes were more than males. best corrected visual acuity up to 6/12 was taken the mean for visual acuity was 0.88. all the subjects with pco and diabetic retinopathy except background stage and with clinically significant cmo were excluded. cause for the poorer chromatic vision following cataract surgery is additionally increased shortwavelength light transmission through intraocular lenses causing retinal damage. in present study it's found that color vision in diabetic pseudophakes was worse in those with background retinopathy for which p value found to be 0.05 showing significant association between color vision and background retinopathy. impairment of color vision found mostly along tritan axis especially for diabetics with retinopathy. the distribution of color defect was 16.9% normal color vision, 10.2% proton and deuteron defect and 61% tritan defect. tritan discrimination sensitivity measurements considered to be as a way of selection for serious retinopathy. there are not enough diabetic pseudophakes with maculopathy and proliferative retinopathy to appear at the results of these conditions on tritan sensitivity. the principle for reduced chromatic vision in diabetic pseudophakes is additionally because of retinal damage by short-wavelength radiations (either from the light microscope or postoperatively). in phacoemulsification there is a shorter quantity once the retinal tissue is exposed to the radiation from the light microscope on removal of the lens. previous study conducted to find color vision in pseudophakes diabetic and normal by knowles and colleages found that color vision decreases after cataract removal both in diabetic and nondiabetic but in diabetic the results are promising depending on severity of diabetes. color discrimination sensitivity was found out in twenty two diabetic pseudophakes with no retiuopathy, twenty three diabetic pseudophakes with background retinopathy and thirty four nondiabetic pseudophakes, all of whom had reasonable vision. in all three groups, red-green discrimination sensitivity was worse inside the pseudophakes (normal’s, p<0.001; no retinopathy, p = 0.467; background retinopathy, p = 0.057). all subjects had extracapsular cataract surgery or phacoemulsification with posterior chamber implants. patients were examined for minimum of three months after cataract surgery. subjects and controls were excluded if their vision was however 6/12, if that they'd had previous optical treatment.11 previous study by gella et al assessed color vision abnormalities in a cohort of subjects with type 2 diabetes mellitus using farnsworthmunsell 100 hue test.10 they found higher proportions of color vision impairment in diabetic subjects with and without retinopathy. most of the subjects were also found to have a blue–yellow color defect. interestingly they reported more color impairment in the females as compared to men.10 the error score was higher in subjects with diabetes having impaired color vision. michael et al exemplified that with increasing age, yellow chromophores continuously accumulate inside the lens in nuclear cataract reducing the transmission of blue light to the retina, and resulting in blue-yellow color vision defects. hence normal age-related color vision changes and those found in diabetic patients are predominantly deficient in the blue– yellow.12 ventruba et al. attributed abnormal color discrimination to a reduction in the transmission of light to the photoreceptors. they further explained that blue vision affect more rather than the red–green mechanism because of the lower density and number of blue cones in the fovea. ventruba et al demonstrated color vision can significantly improve in subjects who underwent cataract surgery.13 our results are in disagreement with ventruba et al as we found more color vision impairment after iol implantation. however, gella et al reported, the presence of posterior subcapsular cataract and negative history of cataract surgery did not show significant association with icv.10 similar to our results previous study performed by radwan etal found tritan deficiency most https://pubmed.ncbi.nlm.nih.gov/?term=gella%20l%5bauthor%5d j aziz fatm med den college july – december 2022, vol. 4. no. 2 12 color vision outcome & phacoemulsification in dm frequently in diabetic subjects with retinopathy. aforementioned study also found color deficiency in the form of deutan and protan and combined color deficiency and total color blindness in few participants. 7 results of fong et al are also in line with current results and found tritan-like visual defect in patients with diabetic retinopathy.14 lopez et al agree with our results and reported the alteration in color vision in 67% of the patients with diabetes and commonest was tritan visual impairment.6 lopz et al did not found protan or deutan color deficiency in their participants.6 current study emphasizes that the impairment in color vision is frequently found in subjects with diabetes, so this aspect of visual impairment should also be considered and assessed great caution routine clinical examination. conclusion the present study was about to determine the impaired color function in pseudophakic background diabetics. it is suggested from the present study that color vision measurements identify a significant loss in performance in diabetic retinopathy group. this study indicates that cataract surgery in diabetics causes more loss of color function usually in tritan axis. loss of color increases with course of retinopathy. the study emphasizes on making the color vision test an integral part of the examination for all the patients undergoing cataract surgery, especially in diabetics. disclaimer: there is no disclaimer. conflict of interest: none funding disclosure: none references 1. kelkar a, kelkar j, mehta h, amoaku w. cataract surgery in diabetes mellitus: a systematic review. indian j ophthalmol. 2018 ;66(10):1401-1410. doi: 10.4103/ijo.ijo_1158_17 2. vieira-potter vj, karamichos d, lee dj. ocular complications of diabetes and therapeutic approaches. biomed res int. 2016;2016:3801570. doi: 10.1155/2016/3801570. 3. tham y, liu l, rim th, et al. association of cataract surgery with risk of diabetic retinopathy among asian participants in the singapore epidemiology of eye diseases study. jama netw open. 2020;3(6):e208035. doi:10.1001/jamanetworkopen.2020.8035 4. wolff be, bearse ma jr, schneck me, dhamdhere k, harrison ww, barez s, et al . color vision and neuroretinal function in diabetes. doc ophthalmol. 2015 ;130(2):131-9. doi: 10.1007/s10633-014-9476-4. 5. kiziltoprak h, tekin k, inanc m, goker ys. cataract in diabetes mellitus. world j diabetes. 2019 15;10(3):140-153. doi: 10.4239/wjd.v10.i3.140. 6. lopez m, martin r, martinez r, garcia j, sanchez r, lopez i, garcia m, mayo a, pastor jc. what is the cause of the impaired color vision in diabetic patients? investigative ophthalmology & visual science. 2002 ;43(13):564. 7. radwan tm, ghoneim em, ghobashy wa, orma aa. assessment of color vision in diabetic patients. international journal of ophthalmic research 2015;1(1):19-23 available from: url: http://www.ghrnet.org/index.php/ijor/article/view/1001. 8. ahmed f, malik fi, azmat ce, gul a, raza a. visual function tests as cost effective screening tools for diabetic retinopathy. pakistan journal of ophthalmology. 2020 22;36(1). 9. tan nc, yip wf, kallakuri s, sankari u, koh yle. factors associated with impaired color vision without retinopathy amongst people with type 2 diabetes mellitus: a cross-sectional study. bmc endocr disord. 2017 2;17(1):29. doi: 10.1186/s12902-017-0181-7. 10. gella l, raman r, kulothungan v, pal ss, ganesan s, srinivasan s, et al. color vision abnormalities in type ii diabetes: sankara nethralaya diabetic retinopathy epidemiology and molecular genetics study ii report no 2. indian j ophthalmol. 2017 ;65(10):989-994. doi: 10.4103/ijo.ijo_601_16. 11. knowles pj, tregear sj, ripley lg, casswell ag. colour vision in diabetic and normal pseudophakes is worse than expected.eye.1996 ;10(1):113-6. doi 10.1038/i.1996.19. 12. michael r, bron aj. the ageing lens and cataract: a model of normal and pathological ageing. philos trans r soc lond b biol sci. 2011;366:1278–92. 13. ventruba j. the influence of iol implantation on visual acuity, contrast sensitivity and colour vision 2 and 4 months after cataract surgery. cesk slov oftalmol. 2006;62:133–43 14. fong ds, barton fb, bresnick gh, early treatment diabetic retinopathy study research group. impaired color vision associated with diabetic retinopathy: early treatment diabetic retinopathy study report no. 15. american journal of ophthalmology.1999;128(5):612-617 j aziz fatm med den college july – december 2022, vol. 4. no. 2 13 nimra gul et al authors’ contribution nimra gul study design, data collection, manuscript writing and data analysis iqra iqbal study design literature search, data collection, drafting amna farooq study design, data collection, drafting, revised and approved all authors are equally accountable for accuracy, integrity of all aspects of the research work and approved the manuscript date of submission: 06-12-2021 revised: 01-08-2022 accepted: 04-08-2022 j aziz fatm med den college july december 2021; vol. 3, no. 2 51 original article knowledge, attitude and practices of dental practitioners against hepatitis b in district faisalabad abid rashid, ume habiba, muhammad asif, naseem akhtar, sultan ayaz, saadia khatoon abstract objective: to assess the knowledge, attitude and practices of dental practitioners against hepatitis b in district faisalabad. methodology: this descriptive cross-sectional study was conducted from 1st august 2019 to 31st january 2020. sixty four dental practitioners who are practicing in allied hospital faisalabad and dhq hospital faisalabad were recruited by using simple random sampling technique, included in this study. the data was collected through selfadministered questionnaires. results: mean age ± sd of the respondents was 31.6±2.8 years. on account of assessing knowledge, 52 dentists strongly agreed for proper hand washing in the prevention of hepatitis b. for using barriers like gloves, gown and masks, 56 of the respondents strongly agreed. for using puncture-resistant containers for sharp disposal, 25 of the respondents strongly agreed. for using protective eye wares 46 agreed. fifty nine of the respondents strongly agreed for the proper sterilization of instruments in the prevention of hepatitis b. on account of practices against hepatitis b, 52 respondents were vaccinated against hepatitis b. twelve were not vaccinated. forty six out of 52 had completed the course of vaccination. five out of 52 failed to recall the history of their vaccination but 6 did not completed the course. conclusion: a good percentage of dental practitioners have been vaccinated against hepatitis b. however, there is a need to increase this percentage, so that maximum number of dentists that come in direct contact with the persons could be prevented against this fatal disease. keywords: knowledge, attitude, practices, hepatitis b, dental practitioners. introduction pakistan is facing one of the world’s top burdens of chronic hepatitis and mortality due to hepatocellular carcinomas, liver failure and cirrhosis. hepatitis b virus is the major cause of hepatic diseases.1 it is a life dr.abid rashid mbbs, fcps, ph.d professor and incharge officer government college university, fsd dr. ume habiba ph.d lecturer government college university, fsd dr. muhammad asif ph.d lecturer government college university, fsd dr. naseem akhtar mbbs, mph lecturer dental section faisalabad medical university, fsd dr. sultan ayaz ph.d assistant professor, government college university, fsd dr. saadia khatoon mbbs, mph pgr obstetrics/gynecology paf hospital isb correspondence: dr. abid rashid email: drabidrashid37@gmail.com threatening liver infection which has become a major health problem all over the world and is a source of other chronic infections and diseases as well. it can lead to liver cirrhosis, hepatocellular carcinoma and has played significant role in increasing mortality rate. vaccine against hepatitis b has been introduced after 1980 which is effective in more than 90% of cases. the vaccine also acts against cirrhosis and chronic diseases.2 the virus can exist for almost one week outside the human body. once it enters into the body it completes its incubation period of almost 75 days. incubation period varies from one month to six months. hepatitis b can be detected within one to two months and can transform in to chronic state.3 virus spreads from infected blood, semen, or other body fluids to noninfected person. transmission from infected mother to child, sex with an infected partner, infected to a noninfected child through negligence is common in spread of disease. it is well documented that almost two hundred and forty eight million people are suffering from chronic hbv infection among the 2 billion people infected with hbv worldwide.4 pakistan is highly endemic with hbv with nine million people infected mailto:drabidrashid37@gmail.com j aziz fatm med den college july december 2021; vol. 3, no. 2 52 with hbv with a steady rise in infection rate. severity depends upon the age at which the person becomes infected. eighty percent of infants infected during the first year of life develop chronic infections. more than 30% of the children less than 6 years of age, get infected with chronic infections. less than 5% of infected adults have the chronic infection. more than 20% of chronically infected adults have liver cirrhosis or hepatocellular carcinoma.5 acute hepatitis b has no specific treatment other than symptomatic treatment. proper and complete nutritional balance should be maintained. care has taken when fluids are wasted through vomiting and diarrhea. different drugs are used in the treatment of chronic hepatitis b infection. these drugs include oral antiviral agents. the progression of cirrhosis can get slow through treatment.6 vaccines are protagonist in spread of hepatitis b. it has been described by world health organization that hepatitis b can be transmitted to infants transplacentally from mothers. vaccination is done in 6, 10 and 14 weeks along with pentavalent vaccine.7 some of the most common causes of hepatitis b in pakistan are the transfusion of unscreened blood, improperly sterilized examination instruments, medical devices. reuse of infected syringe by the health care providers is also a major source of infection in pakistan.8 researchers are conducting studies in pakistan in which the prevalence of hepatitis b are studied. according to that research, more than 2% of hepatitis b hbsag has recorded. in every province, there are more than 28 districts which have a higher prevalence of hepatitis b.9 this study aimed to assess the knowledge, attitude and practices of dental practitioners against hepatitis b in district faisalabad. methodology it was a descriptive cross-sectional study carried out on dental practitioners of allied hospital faisalabad and dhq hospital faisalabad. the stud was approved by ethical review board of government college university faisalabad. the data was collected from 1st august 2019 to 31st january 2020 by using simple random sampling technique, one by keeping all ethical issues in written form and taking informed written consent by the participants. dental practitioners who had been working as regular employees in the selected hospitals were included in the study. the undergraduate dental students and non-dental health professionals were excluded from this study. knowledge was assessed by questions focusing on sign and symptoms, transmission, and role of vaccination regarding prevention of hepatitis b. each response was scored as ‘yes’ or ‘no’. the attitude about dentists at risk for hepatitis b was assessed among respondents. response of the participants was scored as “strongly agree” or “agree”. practices towards hepatitis b prevention were assessed by asking questions about the schedule and dose of vaccine. each response was scored as ‘yes’ or ‘no’. a self-structured questionnaire was developed and a pilot study was done on 5 persons to test the reliability of the questionnaire. after making the necessary changes a final questionnaire was developed and administered among 100 practitioners but complete responses were received from only 64 dental practitioners (n=64). incomplete responses were also excluded from the study. statistical analysis: the data were analyzed using spss version 20. the descriptive statistics were presented in the form of frequencies, bar chart, mean and standard deviation. the questions assessing knowledge, attitude and practices of dental practitioners were presented in the form of frequencies and percentages. the practices indicators were tested by using chi-square test of independence. a p-value <0.05 was considered as showing statistically significant results. results a total of 64 respondents were included in this study. mean age ± sd of the respondents was 31.6 ± 2.8 years. 12 (18%) of the respondents were males, and 52 (82%) of the respondents were females. among all dental practitioners, 27 (42.19%) were married, 31 (48.44%) were unmarried, 2 (3.13%) were widow and 4 (6.25%) were divorced. qualification profile of the respondents showed that 32 (50%) were graduate in dental sciences (bds), 17 (26.56%) had done bds & fellow of college of physicians and surgeons (fcps), 6 (9.3%) had done master bds & master in dental surgery/science (mds) after bds, 5 (7.81%) had done bds, fcps and mrcp, 4 (6.25%) had done bds and mcps degrees both. further results of the study are given below. the participants’ responses on various questions assessing knowledge about hepatitis b transmission and vaccination are shown in table i. out of the 64 dental practitioners, majority, 52(81.25%) of them strongly agreed for the role of proper hand washing in the prevention of hepatitis b. for the role of using barriers like gloves, gown and masks in the prevention of hepatitis b, majority, 56 (87.5%) of kap study dental practitioners against hepatitis j aziz fatm med den college july december 2021; vol. 3, no. 2 53 respondents strongly agreed. for role of using puncture table i: knowledge about hepatitis b transmission and vaccination (n= 64) indicators of knowledge yes (%) no (%) dentists are at higher risk of hbv infection than general population 64 (100) 00 (0%) the causative agent of hepatitis is a virus? 60 (93.75) 4 (6.25) hepatitis b may lead towards cancer/cirrhosis 47 (73.43) 17 (26.56) hepatitis b can be spread by: invasive equipment dental procedures blood transfusion saliva unsterile tattooing personal contact mother to child patient to dentist dentist to patient 62 (96.9) 58 (90.62) 63 (98.43) 56 (87.5) 44 (68.75) 63 (98.43) 58 (90.62) 57 (89.06) 28 (43.75) 2 (3.1) 6 (9.37) 1 (1.5) 8 (12.5) 20 (31.25) 1 (1.5) 6 (9.37) 7 (10.93) 36 (56.25) high number of dentists experience needle stick injury frequently 62 (96.9) 2 (3.1) hbv transmission from patient to dentists and vice versa can be prevented with the use of gloves 63 (98.5) 1 (1.5) table ii: attitude towards preventive measures(n= 64) attitude indicators strongly agree agree neutral disagree strongly disagree dentists should get vaccinated before starting dental practice 49 11 3 1 0 preventive ways should be used against hep b 52 12 0 0 0 barriers (gloves, gown, masks) should be used 56 8 0 0 0 punctureresistant containers for sharp disposal 25 12 9 17 1 use protective eye wares 12 46 5 1 0 proper instruments sterilization 59 5 0 0 0 resistant containers for sharp disposal in the prevention of hepatitis b, less than half 25 (39.06%) of the respondents strongly agreed, and 17 (26.56%) responded as disagree. for the role of using protective eye wares in the prevention of hepatitis b most of the respondents 46 (71.87%) agreed. similarly, majority, 59 (92.18%) of the respondents strongly agreed for the role of proper sterilization of instruments in the prevention of hepatitis b (table ii). out of 64 respondents, a significantly higher number 52 (81.3%) of respondents reported yes about protection against hepatitis b (p<0.05). a significantly higher number 46 (88.4%) of respondents had completed the hepatitis b vaccination course (p<0.001). similarly, a significantly higher number 15 (83.3%) of respondents were willing to complete their vaccination schedule which was left uncompleted (p<0.05) (table iii). reasons behind not completion of the course was 1) carelessness 2) dentists thought that this course was enough and not necessary to complete. when they were asked to complete the course in the future 17% reported that they will not go for the completion of the vaccination and 83% said that they will complete the vaccination procedure. table iii: hepatitis b vaccination profile of respondents (n= 64) practices indicators yes (%) no (%) p-value vaccination done against hepatitis b 52 (81.3) 12 (18.7) 0.003 course completed or not (out of 52) 46 (88.4) 6 (11.6) 0.000 plan to get or complete vaccination (n=18) 15 (83.3) 3 (16.7) 0.036 p value ≤ 0.05 is taken as significant discussion the high prevalence of the blood-borne pathogens and the increasing number of infected patients convince dental professionals to have a thorough knowledge of contagious diseases and the dental management of patients with such diseases. though there is substantial literature regarding the knowledge and attitude of dentists toward other infectious diseases, very few studies have assessed the different categories of dental healthcare professionals and their attitude toward hepatitis b infection, and very few studies have been conducted in pakistan to assess their immunization status.10 the epidemiology of hbv infection varies distinctly throughout areas of the world. hepatitis b is awfully endemic in developing regions with a large population.11 in some areas of the world, most of the population shows past or present serological record of hbv infection. most infection appears during infancy or childhood. most infections in children are asymptomatic, there is little record or confirmation of acute disease related to hbv, but levels of chronic disease and liver cancer in adults are dominant.12 in this study, on account of assessing knowledge, 52 dentists strongly agreed for proper hand washing in the prevention of hepatitis b. for using barriers like gloves, gown and masks, 56 of the respondents abid rashid et al j aziz fatm med den college july december 2021; vol. 3, no. 2 54 strongly agreed. for using puncture-resistant containers for sharp disposal, 25 of the respondents strongly agreed. for using protective eye wares 46 agreed. 59 of the respondents strongly agreed for the proper sterilization of instruments in the prevention of hepatitis b. the present study showed that most of the dentists were aware of the hepatitis b vaccination and its importance. the findings are comparable with the study carried out by pandharbale et al13 and shitoot et al14 which showed the awareness of hepatitis b among dental professionals as 94% and 96% respectively. another study conducted by mahesh et al reported that the level of knowledge regarding the course and transmission of hepatitis b among dental students was satisfactory.15 a study carried out in iran revealed that the level of knowledge, attitude and practices of dentists regarding hepatitis b virus were moderately good.16 on account of practices against hepatitis b in this study, 52 respondents were vaccinated against hepatitis b. 12 were not vaccinated. 46 out of 52 had completed the course of vaccination. 5 out of 52 failed to recall the history of their vaccination but 6 did not completed the course. dentists lacking full vaccination had reasons behind it like carelessness and dentists thought that this course was enough and not necessary to complete. majority of the professionals strongly agreed for the preventive measures for hepatitis b. the results obtained by the study were supported by much of the literature. a study conducted by shitoot et al in india showed that the researcher did a similar type of study among professional dentists although the results were different from the professionals being involved in the present study. nearly one fourth of the dental professionals were not vaccinated against hepatitis b virus, and around half of the dental professionals had not completed their vaccination course.14fewer studies had been done for knowing behaviors of dentists towards preventive measures in pakistan. legitimate hand washing and utilization of barriers , for example, gloves, outfits, and gowns are the principal parts of the standard safety measures which can limit mucocutaneous exposures.17 immunization against hepatitis b should be done for all the dentists before they begin their clinical practice and for susceptible dental practitioners and dental assistant staff. conclusion a good percentage of dental practitioners carry protection against hepatitis b. however, there is a need to increase this percentage, so that maximum number of dentists that come in direct contact with the patients could be prevented against this fatal disease and vice versa. conflict of interest: none funding source: none references 1. butt as, sharif f. viral hepatitis in pakistan: past, present, and future. euroasian j hepatogastroenterol. 2016;6(1):70-81. 2. gerlich wh. do we need better hepatitis b vaccines? indian j med res. 2017;145(4):414-419. 3. guan r, lui hf. treatment of hepatitis b in decompensated liver cirrhosis. international journal of hepatology. 2011;2011:918017. 4. nelson np, easterbrook pj, mcmahon bj. epidemiology of hepatitis b virus infection and impact of vaccination on disease. clin liver dis. 2016;20(4):607-628. 5. madihi s, syed h, lazar f, zyad a, benani a. a systematic review of the current hepatitis b viral infection and hepatocellular carcinoma situation in mediterranean countries. biomed research international. 2020;2020 :7027169. 6. zoulim f, durantel d. antiviral therapies and prospects for a cure of chronic hepatitis b. cold spring harb perspect med. 2015;5(4):a021501. 7. das s, ramakrishnan k, behera sk, ganesapandian m, xavier as, selvarajan s. hepatitis b vaccine and immunoglobulin: key concepts. j clin transl hepatol. 2019;7(2):165-171. 8. asad m, ahmed f, zafar h, farman s. frequency and determinants of hepatitis b and c virus in general population of farash town,islamabad. pak j med sci.2015;31(6):1394-1398. 9. khan a, afzal s, yaqoob a, fatima r, haq mu, junaid k, et al. epidemiology of viral hepatitis b and c in punjab, pakistan: a multicenter cross-sectional study, 2017-18. f1000research. 2019;8(2065):2065. 10. wong f, pai r, van schalkwyk j, yoshida em. hepatitis b in pregnancy: a concise review of neonatal vertical transmission and antiviral prophylaxis. annals of hepatology. 2014;13(2):187195. 11. zara b, min allah nu, javed w, siddique s, mehmood h, hassan f. a cross-sectional assessment of knowledge, attitude, and practices toward hepatitis b virus infection among dentists of tertiary hospitals in islamabad, pakistan. pak oral dent j 2020; 40(2):66-71. 12. qu c, duan z, chen k, zou h. reducing liver cancer risk beginning at birth: experiences of preventing chronic hepatitis b virus infection in china. hepatoma research. 2017;3: 228-240. 13. pandharbale a, gadgil r, bhoosreddy a, ahire b, kunte v, shinde m. an epidemiological study to assess the awareness of hepatitis b infection in the dental students, college staff, practitioners, and auxiliary staff in city of maharashtra. journal of indian association of public health dentistry. 2015;13(2):179-182. 14. shitoot ad, motwani m, chamele dp, shitoot ap, chamele j, ghosh a. hepatitis b awareness and attitudes among dental professionals in central india. journal of indian academy of oral medicine and radiology. 2016;28(3):270. 15. mahesh r, arthi c, victor s, ashokkumar s. hepatitis b infection awareness among dental graduate students: a cross sectional study. international scholarly research notices. 2014;2014. 16. rostamzadeh m, afkhamzadeh a, afrooz s, mohamadi k, rasouli ma. dentists’ knowledge, attitudes and practices regarding hepatitis b and c and hiv/aids in sanandaj, iran. bmc oral health. 2018;18(1):1-8. 17. kretzer d. standard precautions (including hand hygiene and use of ppe). policy. 2018. kap study dental practitioners against hepatitis j aziz fatm med den college july december 2021; vol. 3, no. 2 55 author’s contribution: dr. abid rashid study design, concept, results interpretation write up of results, revised and approved the articles. dr. ume habiba data acquisition, manuscript writing, reviewed and approved the manuscript. dr. m. asif study design, data collection, manuscript writing, and revising manuscript critically for important intellectual content. dr. naseem akhtar data collection, manuscript writing, review the article and approved it. dr. sultan ayaz study design, data analysis and interpretation, revising manuscript critically for important intellectual content. dr. saadia khatoon study design, data analysis, and interpretation of results and formulation of all tables, revised manuscript and approved it. all authors are equally responsible for the validity of the data received: 09 mar 2021, revised received: 20 may 2021, accepted: 22 may 2021 abid rashid et al j aziz fatm med den college jan-june 2020; vol.2, no 1 17 original article burnout syndrome and its risk factors among gynecology consultants khadija asim khan, sarah ejaz, noor-i-kiran naeem, asim khan abstract objective: to assess the frequency of burnout among gynecologists and to determine the factors leading to burnout. methodology: this was a cross-sectional study done at the gynecology and obstetrics department of king edward medical university; lahore from january to june 2017. fifty-five consultant gynecologists, working in public sector teaching hospitals of lahore filled maslach burnout inventory (mbi) proforma for assessment of burnout. the data analysis was performed by spss version 20. results: burnout was found in 13 of 55 (23.6%) consultants. twenty-four participants (43.6%) were having high emotional exhaustion (ee), 41.8% had high depersonalization (dp) and 16.4% had low personal and professional achievement (ppa). single doctors were found to be more burnout as compared to those who were married (p = 0.037). additionally, having private practice was associated with high ee and high ppa. those having higher monthly income were more burnout in ee domain. conclusion: burnout syndrome is common among the consultant gynecologists of public sector healthcare. risk factors for having burnout syndrome include dual practice as well as low monthly salary. keywords: burnout, gynecologist, stress, depersonalization, emotional exhaustion, professional achievement. introduction burnout syndrome is a complex of conditions which may have severe and long-lasting effects on its sufferers. it is assumed to be more prevalent among healthcare workers than general workers because of their stressful nature of job. 1 burnout may have some serious effects on mental as well physical health of the healthcare workers and may lead to fatigue, depression and even cardiovascular events. 2 it may also lead to decreased, poor performance and lower productivity. the quality of life is severely affected and generally overall health system may turn to negative roadmap. 3-5 generally, doctors and particularly surgeons including gynecologists are facing more burnout than other specialties because of more stressful and demanding _____________________________________________________________________ dr. khadija asim khan, mbbs, fcps assis. prof. obstetrics and gynecology, kind edward medical university, lhr dr. sarah ejaz, mbbs, fcps prof. obstetrics and gynecology, red crescent medical college, lhr dr. noor-i-kiran naeem, mbbs, mmed assis. prof. medical education, aziz fatimah medical college, fsd dr. asim khan, mbbs medical officer, dr. rehmatullah hospital gojra correspondence: dr. noor-i-kiran naeem email: noorikiran@yahoo.com job nature. a study from pakistan conducted on nurses, showed that nurses working in gynecology department were most commonly burnout than the other departments and their quality of life was poorest of all. 6 in another study conducted at gynecology and obstetrics department, which included all its staff members , found doctors most commonly facing burnout than nurses and ancillary staff. 7 burnout can be assessed by various tools; however, the most commonly used tool is maslach burnout inventory (mbi). it is a validated tool which has been extensively used in the literature for assessment of burnout syndrome. 8,9 mbi is a 22-item scale with measuring burnout in three domains namely emotional exhaustion (ee), depersonalization (dp) and personal and professional achievement (ppa). 1 many studies and meta-analysis have shown the superiority of mbi over other tools and its psychometric properties have been assessed in many languages and countries. 10,11 limited data is available from pakistan addressing consultants in the gynecology and obstetrics department in terms of burnout. therefore this study was planned with the objective to assess the frequency of burnout among gynecologists and to determine the factors which may lead to their burnout. noor-i-kiran naeem et al. j aziz fatm med den college jan-june 2020; vol.2, no 1 18 methodology this cross-sectional study was conducted at the gynecology and obstetrics department of king edward medical university, lahore. it was conducted after permission from ethical review board of the hospital (269/rc/kemu) from january to march, 2017. all the consultant gynecologists, working in all teaching public sector hospitals of lahore were included in this study via purposive sampling. they were contacted personally and proforma was sent to them either via email or was filled by them on paper. the proforma was anonymous and the doctors were informed that by filling the questionnaire they were consenting to participate in the study. study proforma consisted of two parts. the first contained the demographic details of the participants. the second part contained maslach burnout inventory (mbi) questionnaire. mbi has 22 items and all questions are answered on a 7-point likert scale from 0-6. it is a fully validated tool so it was not validated again for index study. formal permission for using mbi was sought and license for usage was purchased (http://www.mindgarden.com). mbi has shown high internal consistency with cronbach’s α coefficient values of 0.837, 0.869, and 0.881 with high test-retest reliability. the mbi inventory assesses three domains; emotional exhaustion (ee), depersonalization (dp) and personal and professional achievement (ppa). all the three domains are categorized as low, moderate and high. ppa is scored reversed and higher the score, lower is the burnout while for ee and dp, higher is the score, more is the burnout. the cut-off levels for all three domains are provided by the licensure. in this study, burnout was labeled if there is high ee along with high dp or low ppa. statistical analysis: the data was analyzed using spss version 20. quantitative variables were summarized as mean and standard deviation while qualitative variables were summarized as frequency and percentages. risk factors were assessed for overall burnout and three domains of burnout using chi square test and taking p≤0.05 as significant value. results a total of 55 gynecologists were contacted and proforma was filled. the mean age of participants in this study was 42.47 ± 7.07 years with the age range being from 32-56 years. fifty-one participants (92.7%) were female while 4 participants (7.3%) were male. the most common fellowship degree was fcps (96.4%) and 92.7% were married. additionally 53 participants (96.4%) felt satisfied with their specialty (table 1). table 1: demographic details of participants mean ±sd age 44.89 ± 8.50 gender male female 4 (7.3%) 51 (92.7%) post-graduate experience 0-5 years 6-10 years 11-20 years >20 years 19 (34.5%) 18 (32.7%) 13 (23.6%) 5 (9.1%) fellowship degree fcps mcps 53 (96.4%) 2 (3.6%) marital status single married 4 (7.3%) 51 (92.7%) working hours/weak 50-60 hours 61-80 hours more than 80 hours 8 (14.5%) 16 (29.1%) 31 (56.4%) private practice yes no 37 (67.3%) 18 (32.7%) income per month <60 thousand pkr 60-100 thousand pkr >100 thousand pkr 17 (30.9%) 25 (45.5%) 13 (23.6%) are you satisfied after choosing this specialty? yes no 53 (96.4%) 2 (3.6%) participants were labeled burnout if they had high ee along with either high dp or low ppa. it was found that 23.6% consultants were facing burnout syndrome. twenty-four participants (43.6%) were having high ee, 41.8% had high dp and 16.4% had low ppa (figure 1).also 70.9% of the respondents were having burnout in at least one domain of mbi. additionally it was found that all the 13 participants who had burnout were those who felt satisfied, while the two participants who were unsatisfied, were not having burnout according to mbi. factors leading to burnout were also assessed. taking overall burnout, it was found that single doctors were more burnout than the married ones (p = 0.037). no impact of age on burnout levels was noticed (p value = 0.89). burnout was assessed for all three domains with the findings that having private practice was associated with high gynecologists who are also doing private practice along with public sector job (p value = 0.01). doctors having income between burnout among gynecologist j aziz fatm med den college jan-june 2020; vol.2, no 1 19 figure 1: burnout among study participants ee=emotional exhaustion, dp=depersonalization ppa=personal and professional achievement 60-100 thousand pkr have comparatively higher burnout ppa (table 2). higher levels of burnout were found in low paid than in high paid doctors (p value= 0.04) (table 2). table 2: significant risk factors for burnout yes no pvalue marital status 0.03* single ( n=4) 3( 75%) 1 (25%) married (n=51) 10 (20%) 41(80.3%) emotional exhaustion low moderate high private practice 0.01* yes (n=37) 6 (16.2%) 10 (n=27%) 21(56%) no (n=18) 8(44%) 7(n= 38.8%) 3 (16.6%) income 0.04* <60,000 pkr(n=17) 8 (47) 5(29.4) 4(n=23.5) 60-100,000 pkr (n=25) 6 (24) 8(32) 11(44) >100,000 pkr(n=13) 0(0) 4(30.7) 9(69.2) personal & professional achievement private practice 0.006* yes (n=37) 4(10.8) 6(16.2) 27(72.9) no (n=18) 5(27.7) 8(44.4) 5 (27.7) p value < 0.05 is significant discussion the main objective of this study was to determine the frequency of burnout among gynecologists and to identify the leading risk factors. the burnout among gynecologists was found to be 23.6%. martini et al conducted a study on eight different specialties residents and found gynecology residents showing the prevalence of burnout to be as high 75%. 12 similar results shown by castelo, branco et al where 58 % gynecology residents fulfilled the criteria of burn out syndrome 13 . the reason for this difference may be due to that our study group were mainly comprised of consultant as compare to residents in above both studies. in a study conducted on medical professionals deployed in afghanistan from us, showed that burnout was higher in those having less team member care and self-caring attitude. 14 in a large study on medical oncologists that had included oncologists from 51 countries, it was found that single marital status was significantly more commonly associated with burnout syndrome. also they found having a younger age was a significant risk factor for burnout. 15 our results are in line with above mentioned study, as was found burnout in unmarried doctors than married doctors. burnout is called a syndrome because all of its aspects and outcomes have not yet been discovered and studied. a research on nursing students, authors identified 60 important factors which may lead to burnout and their experts panel admitted that many of them have not been studied yet 16 . therefore lot of research has to be done on burnout in order to have better understanding of the issue. this study showed that gender had no relation with overall burnout nor its subscales. similar findings were narrated by lahana et al in a study on nurses. 17 however, vassos et al have suggested that being a male does predispose to high ee and dp. 18 in current study, age of the participants and experience of work were also not associated with burnout. again the literature shows contrary results over this risk factor. kilfedder et al have shown that higher age is usually associated with less ee because of more experience and higher ppa 19 . however, our results are supported by hastings et al study that reported no impact of age over burnout prevalence. 20 in contradiction to current results, recent study from karachi has suggested moderate burnout was more prevalent in males and married as compared to single subjects. this aforementioned previous study also reported lesser burnout levels among participants with older age as compared to younger age. 21 current results also revealed that doctors who are involved in private 0 5 10 15 20 25 30 35 ee dp ppa 14(25.4%) 23(41.8%) 9(16.3%) 17(30.9%) 19(34.5%) 14(25.4%) 24(43.6%) 23(41.8%) 32(58.1%) f e r q u e n c ie s low moderate high noor-i-kiran naeem et al. j aziz fatm med den college jan-june 2020; vol.2, no 1 20 practice along with jobs in public sector have higher levels of burnout, might be because of overburden and hectic stressful job routine. furthermore we also noticed higher burnout levels in doctors having pay between 60-100 thousand pkr as compared to doctors having pay greater than 100 thousand pkr. these finding are supported by liaqat et al study conducted at lahore. 1 doctors should be paid more by government hiring agencies, so they can avoid to do private practice along with their public sector stressful jobs to reduce burnout among these front line soldiers. limitations and recommendation: the limitation of this research was that since it was a simple cross-sectional study without any intervention for treatment/prevention of the burnout syndrome, therefore its results cannot be generalized and spatial conclusion can be drawn. however, this study was unique, particularly in a developing country which has addressed gynecologists particularly. conclusion: burnout among gynecologists working in public sector is quiet frequent with high scores in one domain at least. burnout was common in unmarried than married doctors. it is recommended to take preventive measures in order to save the gynecologists form this syndrome and to improve their quality of life. conclusion: burnout syndrome is common among the consultant gynecologists of public sector healthcare. risk factors for having burnout syndrome include dual practice, being married as well as low monthly salary. funding source: none. conflicts of interest: none. references 1. liaqat n, dar sh, waheed k. burn out among the paediatric surgeons of pakistan. j pak med assoc. 2019 ;69(11):1730-1733. doi: 10.5455/jpma.300916 2. cohen r, bavishi c, haider s, thankachen j, rozanski a. meta-analysis of relation of vital exhaustion to cardiovascular disease events. am j cardiol 2017;119:121 1-1216. doi: 10.1016/j.amjcard.2017.01.009, review. 3. pantenburg b, luppa m, konig hh, riedel-heller sg. burnout among young physicians and its association with physicians' wishes to leave: results of a survey in saxony, germany. j occup med toxicol. 2016;11:2 doi: 10.1186/s12995-016-0091-z. 4. maroco j, maroco al, leite e, bastos c, vazao mj, campos j. burnout in portuguese healthcare professionals: an analysis at the national level. acta med port. 2016;29 (1) 24-30. doi: 10.20344/amp.6460. 5. dyrbye ln, west cp, satele d, boone s, tan l, sloan j, et al. burnout among u.s. medical students, residents, and early career physicians relative to the general u.s. population. acad med. 2014; 89:443-51. doi: 10.1097/acm.0000000000000134. 6. naz s, hashmi am, asif a. burnout and quality of life in nurses of a tertiary care hospital in pakistan. j pak med assoc. 2016;66 (5):532-536. 7. fontan atalaya im, duenas diez jl. burnout syndrome in an obstetrics and gynaecology management unit. rev calid asist. 2010;25(5):260-267. doi: 10.1017/sjp.2016.91. 8. tomas jm, de los santos s, alonso-andres a, fernandez i. validation of the maslach burnout inventory-general survey on a representative sample of dominican teachers: normative data. span j psychol. 2016;19:e83. 9. montiel-company jm, subirats-roig c, flores-marti p, bellot-arcis c, almerich-silla jm. validation of the maslach burnout inventory-human services survey for estimating burnout in dental students. j dent educ. 2016;80(11):1368-1375. 10. matejic b, milenovic m, kisic tepavcevic d, simic d, pekmezovic t, worley ja. psychometric properties of the serbian version of the maslach burnout inventory-human services survey: a validation study among anesthesiologists from belgrade teaching hospitals. scientificworldjournal. 2015;2015:903597. doi: 10.1155/2015/903597. 11. campos ja, maroco j. maslach burnout inventory student survey: portugal-brazil cross-cultural adaptation. rev saude publica. 2012;46(5):816-824. doi: 10.1590/s003489102012000500008. 12. martini s, arfken cl, churchill ma, balon r. burnout comparison among residents in different medical specialties. acad psychiatry. 2004;28(3):240-242. doi: 10.1176/appi.ap.28.3.240. 13. castelo‐branco c, figueras f, eixarch e, quereda f, cancelo m, gonzalez s, et al. stress symptoms and burnout in obstetric and gynaecology residents. j bjog.2007;114 (1):94-98. doi: 10.1111/j.1471-0528.2006.01155.x. 14. adler ab, adrian al, hemphill m, scaro nh, sipos ml, thomas jl. professional stress and burnout in u.s. military medical personnel deployed to afghanistan. mil med. 2017;182(3):e1669-e1676. doi: 10.7205/milmed-d-1600154. 15. banerjee s, califano r, corral j, de azambuja e, de mattos-arruda l, guarneri v, et al. professional burnout in european young oncologists: results of the european society for medical oncology (esmo) young oncologists committee burnout survey. ann oncol. 2017;28(7):15901596. doi: 10.1093/annonc/mdx196. 16. manzano-garcia g, ayala jc. insufficiently studied factors related to burnout in nursing: results from an e-delphi study. plos one. 2017;12(4):e0175352. doi: 10.1371/journal.pone.017535 https://www.ncbi.nlm.nih.gov/pubmed/31740889 https://www.ncbi.nlm.nih.gov/pubmed/31740889 burnout among gynecologist j aziz fatm med den college jan-june 2020; vol.2, no 1 21 17. lahana e, papadopoulou k, roumeliotou o, tsounis a, sarafis p, niakas d. burnout among nurses working in social welfare centers for the disabled. bmc nurs.2017;16: 15. doi: 10.1186/s12912-017-0209-3. 18. vassos mv, nankervis kl. investigating the importance of various individual, interpersonal, organisational and demographic variables when predicting job burnout in disability support workers. res dev disabil. 2012;33(6):1780-1791. doi: 10.1016/j.ridd.2012.04.016. 19. kilfedder cj, power kg, wells tj. burnout in psychiatric nursing. j adv nurs. 2001;34(3):383-396. doi: 10.1046/j.1365-2648.2001.01769.x 20. hastings rp. do challenging behaviors affect staff psychological well-being? issues of causality and mechanism. am j ment retard. 2002;107(6):455-467. doi: 10.1352/0895-8017(2002)107<0455:dcbasp>2.0.co;2. 21. ahmed t, shah h, rasheed a, ali a. burnout among nurses working at dow and civil hospitals in karachi: a cross-sectional study. j pak med assoc.2020;70(6):10181022.doi:https://doi.org/1 0.5455 /jpma.27407. author’s contribution: dr. khadija asim khan idea conception and data collection, critically revised and approved manuscript, accountable for data and whole material provided in manuscript. dr. sarah ejaz data collection, manuscript writing, accountable for material provided, revise and approve final version. dr. noor-i-kiran naeem data analysis, manuscript writing and accountable for material provided in manuscript. dr. asim khan data collection, manuscript writing and accountable for material provided in manuscript. received: 11 april 2019, revised received: 13 august 2019, accepted: 23 september 2019 j aziz fatm med den college july – december 2022, vol. 4. no. 2 25 original article stress and its influencing factors among intern nurses during pandemic outbreak of covid 19 muhmooda abdul razzaque, sabir hussain, ghulam qadir, yasmin azad, abdul wahid abstract: objectives: to investigate the frequency of stress and its influencing factors among intern nurses during the pandemic outbreak of covid-19 in karachi, pakistan. methodology: this descriptive study was conducted among intern nurses who were working in different hospitals of karachi, pakistan from 15th august to 15th september 2021. a total of 400 intern nurses were enrolled by using purposive sampling technique. inclusion criteria: intern nurses who were assigned in covid-19 department/units. exclusion criteria: intern nurses who were not willing or absent at the time of data collection. data were collected through a questionnaire and consists of three sections: first section included a general health questionnaire (ghq-12). second section is about influencing factors of stress, and third section encompassed with demographic information. the data were analyzed by using spss 20. results: out of total 400 intern nurses, n=305 (76%) were in a high stress and n=95 (24 %) were reported a low stress. four influencing factors were significantly (p-value<0.05) associated with level of stress of intern nurses. i.e.: chances of having an infection (pvalue=0.005), inadequate personal protective equipment (pvalue= 0.000), guilt to be a nurse (pvalue= 0.003), and long hours of duties (p value= 0.001). conclusion: present study had explored that majority of intern nurses were in high stress and four influencing factors were significantly associated with level of stress. such as chances of having an infection, inadequate personal protective equipment and guilt to be a nurse, long duty hours. keywords: intern nurses, stress, influencing factors, covid-19 introduction covid-19 disease is a health crisis globally. according to w.h.o global report morbidity and mortality rate are still very high with current ms. muhmooda abdul razzaque, msn lecturer, institute nursing and midwifery dow university of health sciences ojha campus, khi, pakistan. sabir hussain associate professor shaheed muhtarma benazir bhutto university larkana, pakistan ghulam qadir msn senior lecturer united college of nursing and midwifery korangi, karachi yasmin azad msn assistant registrar pakistan nursing council islamabad, pakistan abdul wahid msn lecturer shaheed muhtarma benazir bhutto university larkana, pakistan correspondence: ms. muhmooda abdul razzaque, email: mahmooda.duhs@gmail.com estimates of 649,038,437 and 6,645,812 respectively.1,2 as mortality and morbidity increased worldwide it provoked significant stress level of nurses.3 this is because of nurses were first witnesses of covid-19 patient’s disease severity and painful deaths of covid-19 patients.1,2 according to lai et al study, health care professionals are suffering from psychological distress during covid-19 pandemic due to raising number of cases and deaths.4 moreover this stress full condition was aggravated due to shortage of health care providers and personal protective equipment, coworkers infected with covid-19, ineffective preventive measures and inadequate support from supervisors, seniors and peers.4 internship is transitional phase of student nurses in which they may learn to integrate theoretical knowledge into clinical practice.5 it may build them cognitive and reflective abilities to perform nursing skills. during this time, they are being trained into a various clinical setting from mailto:duhs@gmail.com j aziz fatm med den college july – december 2022, vol. 4. no. 2 29 mahmooda abdul razzaque et al intensive care units (icu) to high dependent unit (hdu) and general wards.5 usually, intern nurses are in stress during this period (internship) that is considered normal due to novelty of their practice at clinical settings.5 according to elsaid et al (2020) study in egypt, found 100% of intern nurses had stress during their internship in prepandemic (covid-19).6 globally, in this pandemic situation hospital and clinical staff were restructured to handle the heavy flow of covid-19 patients.7 due to shortage of registered nurses, intern nurses were assigned in covid-19 departments as a soldier to help patients to fight against covid-19.4,5 one of the survey highlighted that pandemic covid-19 has changed traditional type of clinical practice of internship and intern nurses trapped into ethical and legal dilemma.8 it increased strain level of intern nurses about risk of infection and fear of transmitting of infection to patients, colleagues, friends and families.9 this also exposed intern nurses to various stressors. such as regret to be part of nursing profession, dissatisfaction and feeling of tiredness, long duty hours and lack of appreciation from seniors.8,9 a descriptive study highlighted that intern nurses were in stress due to unpredictable workload and assignments.6 one of the studies found that reason of stress among intern nurses and in health care providers were restriction on meeting with their family members.8,9 at present time, there is dearth of literature of previous studies which solely linked to stress of intern nurses during the pandemic covid19. therefore, it is mandatory to investigate frequency of stress and its influencing factors among intern nurses during pandemic covid19 in karachi. furthermore, current study is considered to establish a base for intervention related to mental distress of intern nurses in karachi, pakistan. methodology this descriptive study was conducted at different hospitals of karachi, pakistan among intern nurses from 15th august to 15th october, 2021. the study was approved by irb (institutional review board) of dow university of health sciences of karachi (ref: irb2130/duhs/approval/2021). before data collection, consent was obtained from all study participants. a purposive sampling technique was used to enroll participants in the study. inclusion criteria: intern nurses who were assigned in covid-19 department/units. exclusion criteria: intern nurses who were not willing or absent at the time of data collection. sample size of the study was calculated by using “open epi software” by considering 50% of estimated population,5% of margin of error and 90% of confidence of interval. on initial stage, calculated sample size was 384 which was raised to 400 to cover dropout rate of participants. according to objectives of study, two open access, well-structured questionnaire was adapted, which were used in previous studies.4,8 furthermore, cronbach’s alpha coefficient test illustrated validity and reliability of questionnaire that was 0.78 and 0.82 collectively after 10% of pilot study. the questionnaire has three sections: section one included 12 items of general health questionnaire (ghq-12). it is comprised of four point likert scale (0= no symptoms, 1 = usual symptoms, 2 = more symptoms than usual, and 3= symptoms that is much more than usual). total marks ranging from 0 to 36. the presence of low and high stress among intern nurses established through cut off value (if it is ≤ to 18, it is marked low stress), and (if it is > 18, it is marked high stress). section two included 10 influencing factors of stress of intern nurses. for example: chances of having an infection, inadequate personal protective equipment and guilt to be a nurse, long duty hours, lack of sleep and feeling fatigue, and support from colleagues and supervisors, occupational competence, heavy workload, dissatisfied with pre-internship orientation and frequent hand wash. participants had 02 options to response (yes or no). section three comprised of demographic information of intern nurses. such as age, gender, clinical setting, working experience and frequently use of social media. the data were analyzed by using spss 20. frequencies and percentages were used to find stress and its influencing factors. bar charts were used for pictorial view of stress. furthermore, chi square test was applied to analyze the significant relationship of stress with its influencing factors. j aziz fatm med den college july – december 2022, vol. 4. no. 2 29 mahmooda abdul razzaque et al p-value <0.05 was considered as a statistically significant. results in current study, a total 400 intern nurses participated, 305(76%) were in high stress and95(24%) had low stress (figure1) four influencing factors were significantly related to level of stress among intern nurses. for instances: probabilities of getting infection of covid-19, inadequacy of personal protective equipment, and guilt to be a nurse, long hours of duties (table: 1). a majority of intern nurses who were in high stress; whose age less than 25 years 200(65.5%), mostly were female 250(81.9%), and working in intensive care unit 180(59.0%) and clinical experience was lies between 1 to 4 months 122(40.0%) and used social media frequently 220 (72.1%) (table: 2). table:1 influencing factors of stress among intern nurses inflencing factors high stress low stress p n= 305 (76%) n= 95 (24%) value 1. probabilities of getting infection yes 240(78.7) 50 (52.6) 0.005* no 65(21.3) 45 (47.4) 2. inadequate personal protective yes 220 (72.1) 55 (57.9) 0.000* equipment (ppe) no 80(27.9) 40 (42.1) 3.regret on decision to become nurse yes 150 (49.2) 45 (47.4) 0.003* no 155(58.8) 50 (52.6) 4. long hours of duties yes 230(75.5) 30 (31.6) 0.001* no 75(24.5) 65 (68.4) 5. lack of sleep and feeling fatigue yes 125(41.0) 75 (78.9) 0.024 no 180(59.0) 20 (21.0) 6. lack of support from colleagues and yes 115(37.7) 54(56.8) 0.125 supervisors no 190(62.3) 41(43.2) 7.occupational competence yes 210 (68.9) 45(47.4) 0.345 no 95 (31.1) 50(52.6) 8.heavy workload yes 128(42.0) 70(73.7) 0.501 no 177(58.0) 25(26.3) 9. dissatisfied with pre-internship yes 212(69.5) 60(63.2) 0.532 orientation no 93(35.5) 35(36.8) 10.frequent hand wash yes 100(32.8) 70(73.7) 0.078 no 205(67.2) 25(26.) chi-square test (p-value <0.05) figure 1: level of stress among intern nurses dissucion in current study, a total 400 intern nurses participated in study, and 305(76%) were in high stress and 95(24%) had low stress. these findings were in-lined with previous descriptive studies which was conducted among health care professionals in egypt, japan and turkey.6,10,11 however contradicted findings were reported by studies conducted in various countries such as indonesia italy, mirpur khas, pakistan, china, table: 2: demographic factors of level of stress among intern nurses items high stress 305(76%) low stress 95(24%) age <25 years 200(65.5) 22(23.2) 26-30 years 106(34.7) 48(50.5) 31-35yearrs 94(30.8) 25(27.1) gender male 150(49.1) 50(52.6) female 250(81.9) 45(47.3) clinical setting covid-19 icu 180(59.0) 31(32.6) covid-19 hdu 153(50.1) 24(25,2) covid-19 ward 67(21.9) 40(42.1) clinical experience 1 to 4 months 122(40.0) 15(15.7) 5 to 9 months 43(14.0) 38(40) more than 10 months 35(11.4) 42(44.2) use of social media frequently yes 220(72.1) 20(21.0) no 80(26.2) 75(78.9) 80% 70% 60% 50% 40% stress 30% 20% 10% 0% high stress low 24 % 76% j aziz fatm med den college july – december 2022, vol. 4. no. 2 29 mahmooda abdul razzaque et al new york a n d india. 12-17 moreover, wasim et.al investigated that overall health care providers were suffering from psychological problems in facility of health provision while caring of during covid-19. maximum nursing staff were in high level of stress.18 present study has explored four influencing factors which were significantly related to level of stress. for examples: probabilities of getting infection of covid-19, inadequacy of personal protective equipment, and guilt on decision to be a nurse, long hours of duties. similar findings were supported by numerous descriptive studies that had been found significant relationship with factors of stress. for instances; spreading of covid-19 infection to their families, regarding ppe, lengthy duty hours, physical and mental fatigue and lack of training before full time duties.8,10,16,17 nursing professionals have played a vital role during covid-19.18,19this pandemic caused worst situations in pakistan because of limited resources and nurses were not fully protected with personal protective equipment.19 furthermore, few researches emphasized forproper training and facilitation of intern nurses before recruitment into clinical settings. so, mental health of intern nurses may be ensured from unavoidable condition of stress.5,6 in present study, most of intern nurses who were in high stress; whose age less than 25 years 200(65.5), female 250(81.9), working in intensive care unit 180(59.0) and clinical experience was lies between 1 to 4 months 122(40.0) and used social media frequently 220 (72.1). few studies findings were supported that intern nurses whose age group lies between 23 to 24 years, and had 8 months of clinical experience and their duty placement was in adult ward experienced more stress.20,21 moreover, similar findings were supported by imran et.al among postgraduate trainees that female participants had risk of psychological distress as compare to male participants.22 in contrast, study had found that male intern nurses had low stress as compare to female.17 studies showed that female perception is quite different from male.22,23 moreover, women are more vulnerable to stress and affected by social norms.23 conclusion present study found that majority of fresh intern nurses who were, working in intensive care unit, were more stressed. four influencing factors were significantly associated with level of stress of intern nurses. for instance: chances of having an infection, inadequate personal protective equipment and guilt to be nurse, long duty hours. conflict of interest: none funding agency: none references 1. worldhealth. org. who coronavirus (covid-19) 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(2021) ;47(3):282-291. doi;10.1007/s00134021-06352-y 8. sperling d. ethical dilemmas, perceived risk, and motivation among nurses during the covid-19 pandemic. nurse ethics. 2021 ;28(1):9-22. doi;10.117710969733020956376. 9. safan sm, ebrahim rm. problems and obstacles facing nursing interns and its relation to their performance at clinical setting: a comparative study. american j nurse. 2018;7(6):304-313. doi: 10.11648/j.ajns.20180706.24 10. ishikawa m, ogasawara t, takahashi k, ono t, matsui k, marshall s, et al. psychological effects on healthcare workers during the covid-19 outbreak: a single center study at a tertiary hospital in tokyo, japan. internal med. 2021;60(9):2771-2776. doi;10.2169/internalmedicine.7207-21. 11. aslan i, ochnik d, çınar o. exploring perceived stress among students in turkey during the covid-19 pandemic. int j environ res public health. 2020;17(23):896170. doi;10.3390/ijerph 7238961. j aziz fatm med den college july – december 2022, vol. 4. no. 2 29 mahmooda abdul razzaque et al 12. fathiariani l, nassimbwa j. investigating the burden of mental distress among nurses at a provincial covid-19 referral hospital in indonesia: a cross-sectional study. bmc nurse. 2021;20(1):1-8. doi;10.1186/s/2912-021-00596-1 13. benfante a, di tella m, romeo a, castelli l. traumatic stress in healthcare workers during covid-19 pandemic: a review of the immediate impact. front psychol. 2020 ;23 (11):28 -35. doi;10.3389/fpsyg.2020.569935. 14. asif s, noor fa, nawaz z. assessment of frequency and severity of stress among the students of state school of nursing mirpur ajk by application of perceived stress scale. age (years). pjmhs.20 2020;14 (3):1067-1069 15. mo y, deng l, zhang l, lang q, liao c, wang n, et al. work stress among chinese nurses to support wuhan in fighting against covid 19 epidemic. j nurse manag. 2020 ;28(5):1002-1009. doi; 10.111/jonm.13014. 16. shechter a, diaz f, moise n, anstey de, ye s, agarwal s, birk jl, brodie d, cannone de, chang b, claassen j. psychological distress, coping behaviors, and preferences for support among new york healthcare workers during the covid-19 pandemic. gen hosp psychiatry.2020 ;66(1):1-8. doi; 10.1016/j.genhosppsych.2020.06.007. 17. huded cb, rasquinha sl, rao p. psychological impact of covid-19 on medical interns–findings from a nationwide survey. j edu health promot. 2021;10(1): 155171. doi;10.4103/jehp-33-21. 18. wasim t, e raana g, bushra n, riaz a. effect of covid-19 pandemic on mental wellbeing of healthcare workers in tertiary care hospital. annals of king edward medical university. 2020;26(special issue):140-144. doi;10.21649/ akemu. v26i special issue.3625 19. mansoor s, azad n, bin zubair u, waqar t, butt a, ul ain q. mental health impact of the covid-19 pandemic on frontline healthcare workers at a tertiary care hospitain rawalpindi, pakistan. j p psych soc. 2020;17(4):7-12 20. said rm, el-shafei da. occupational stress, job satisfaction, and intent to leave: nurses working on front lines during covid-19 pandemic in zagazig city, egypt. environ sci pollut res int. 2021 ;28(7):8791-8801. doi; 10.1007/s11356020-11235-8. 21. sanghera j, pattani n, hashmi y, varley kf, cheruvu ms, bradley a, burke jr. the impact of sars-cov-2 on the mental health of healthcare workers in a hospital setting a systematic review. j occup health. 2020;62(1):3-16. doi;10.1002/13489585.12175. 22. imran n, masood hm, ayub m, gondal km. psychological impact of covid-19 pandemic on postgraduate trainees: a cross-sectional survey. postgrad med j. 2021;97(1152):632-637. doi;10.1136/postgradmedj-2020-138364 23. rabbani f, khan ha, piryani s, khan ar, abid f. genderspecific psychological and social impact of covid-19 in pakistan. b j psych open. 2022;8(1) 1-8. doi.org/10.1192/bjo.2021.10 authors’ contribution muhmooda abdul razzaque study concept and design, literature search, data collection, analysis, first draft write-up. sabir hussain study design, literature search, data collection, final draft writes up. ghulam qadir study concept and design, analysis, final review, overall supervision. yasmin azad data collection, statistical analysis approved the manuscript. abdul wahid study concept, data analysis, interpretation of results & approved the manuscript. all authors are equally accountable for search work and integrity. date of submission: 18-10-2022 revised: 21-11-2022 accepted: 16-12-2022 j aziz fatm med den college january – june 2022; vol. 4, no. 1 26 original article probing the therapeutic effects of bamboo shoots supplementation on diabetic male and female patients laraib imdad, m adeel alam shah, javaid hassan, farhat humayun, ayesha sadiq, mavish javed abstract objective: to check whether bamboo shoots help to lower blood glucose level in type ii diabetic patients. methodology: prospective experimental study was conducted in district faisalabad from january to march 2016 after approval from ethical committee and advance study & research board university of agriculture faisalabad (uaf). all samples were collected from allied hospital faisalabad and family polyclinic faisalabad. both male and female with type ii diabetes mellitus with different age groups (ranging from 40 to 60+ years) were included in the study and exclusion criteria were applied. fine grinded bamboo-shoot powder prepared in uaf lab was supplemented in cookies at different doses and was given to them. blood sugar level was monitored at different intervals from 0 to 120 minutes. data was recorded. results: study was comprised of 20 male and 20 female diabetic subjects with mean and sd age 51 ± 0.78 years. current result revealed that blood glucose level was decreased gradually in 120 minutes of period after eating bamboo shoots supplemented cookies as compared to control group. it was noted that increased dose of bamboo shoots lowers the blood glucose concentration with significant difference. lowest blood glucose concentration was observed after taking highest dose of bamboo shoots of 20 gram (t10 dose) (p value 0.00). the results showed highest score for g.i for t0 (79.19±2.74) and the lowest for t10 (64.68±1.78), representing the consumption bamboo shoot significantly reduces glycemic index (p value = 0.00). conclusion: glycemic control was improving with increasing the dose of bambooshoot in cookies. keywords: bamboshoots, glycemic index, diabetes introduction type ii diabetes mellitus is a worldwide most laraib imdad bs (hon), mphil university of agriculture, fsd dr. m adeel alam shah mbbs, mphil assistant professor independent medical college, fsd dr. javaid hassan mbbs, mphil assistant professor muhammad college of medicine, pew dr. farhat humayun mbbs, mphil assistant professor abwa medical college, fsd dr. ayesha sadiq mbbs, mme woman medical officer govt. general hospital g.m abad, fsd dr. mavish javed mbbs, mphil assistant professor khyber girls medical college, pew correspondence: dr. m adeel alam shah email: dr.adeelalam@gmail.com common problem. it is a major health issue of both genders above 40 years, which is likely to be increase in number over next ten years.1 dietary habits and life style plays a major role in persons health, as in modern era people are more prone to eat extra processed food and high sugar drinks which is one of the leading cause in weight gain and causing insulin resistant diabetes.2 lack of exercise, over stressed environment and lack of social activities are in correlation of having diabetes in later age.3 all over the world, bamboo shoots are used for various purposes like medicine and food from earlier times.4,5 these are also used in different foods especially in east asian countries. few portions of young bamboo plants are used as an herbal medicine by human beings but there is a lack of scientific study on its medical significance. bamboshoots contain multiple nutritive materials such as protein, starches, fats, minerals, enzymes, vitamins, reducing & nonreducing sugars, lactic and citric acids. they contain little fats and calories.6 studies shows that they are also rich in nutrients and prebiotic properties which reduce blood cholesterol and ldl, moreover also help in weight loss and relieve constipation.7, 8 in type 2 diabetes due insulin resistance, dietary fibers help to maintain blood glucose levels, gut motility, enhancement of bowel health and reduce in weight as an adjunct therapy, this has been studied in 2020.8 another study published in 2018 revealed the therapeutic role of dietary fibers in the disease of mailto:dr.adeelalam@gmail.com j aziz fatm med den college january – june 2022; vol. 4, no. 1 27 diverticulosis via reduction of pressure in large intestine.9 also in 2018 study, it was assessed that the incidence of americans citizens diagnosed with diabetes mellitus (dm) have been raised thrice in number which is approximately from 5.8-20.9 million, thus leads to diabetic complications associated with high mortality rate.10 nowadays the dietary habits are changed; there is a significant increase intake of fat and total cholesterol and deceased intake of dietary fiber contents, which resulted in obesity and cardiovascular diseases.11 so it was a need of the day to conduct a study on therapeutic role of bamboo shoots as a dietary fiber in reducing blood sugar levels. the aim this study was to check whether bamboo shoots help to lower blood glucose level in type ii diabetic patients. methodology after approval from graduate committee and ethical research board of institute of home science, university of agriculture faisalabad, a prospective experimental study was conducted on male and female patients previously diagnosed with type ii diabetes mellitus in year 2016 from january to march with letter number ce/2641. after informed consent samples were taken from medical outdoor allied hospital faisalabad and family polyclinic faisalabad. all samples from age 40 to 60 years old were included with no prior history of any other chronic illnesses other than diabetes or on insulin therapy. a questionnaire was made in order to record their medical history, tests profile, medical treatment and exclusion criteria were applied. in our study, fine flour was supplemented with bamboo shoots to prepare cookies. bamboo shoots were collected from gutwala park faisalabad. dendrocalamus hamiltonii specie of bamboos was used. the fine flour was arranged from laboratory of university. other material such as oil, sugar, salt and baking powder was bought from local market of faisalabad. bamboo shoots were thoroughly washed, chopped into small pieces with cutting knife and then boiled for 3-4 hours at 100 0c. they were dried in oven at 72°c for 24-hours. after this, bamboshoots were finely grinded to powder. by mixing of bamboo shoots powder from 1% to 10% in fine flour, composite flour was prepared. according to criteria of aacc (2000) fortified flour was used to prepare cookies. then all ingredients were added in hobart mixer following a specific sequence. the contents were mixed until they converted to a homogeneous mass. the batter was rolled. cookies were formed by 50mm cookie cutter. these cookies were baked at temperature of 210 °c for 18-20 minutes and set to be cooled at ambient room temperature. then these cookies were kept at room temperature in separate containers. all of these cookies were made from different doses of bamboo shoots and labeled them with english alphabet “t” and numerical number “n” such as t2, t4, t6, t8 and t10 with dosage 2, 5, 10, 15 & 20 grams respectively. the control group was labeled as t0, due to zero concentration of bamboo shoot powder. after applying exclusion criteria all selected patients were asked not to take their anti-diabetic medicine on that day, and eat three cookies according to treatment number assigned to them. their blood sugar levels were monitored by “accu-check” glucometer with intervals of 15 minutes starting from 0 minute to 120 minutes. data were recorded against each patient’s profile and type of treatment given to them according to above dosage. statistical analysis: data analysis was performed by using spss v22, continues variables are presented as mean and standard deviations.means are compared by anova. p value ≤ 0.05 was taken as significant results twenty males and twenty females with type ii diabetes were enrolled for the experiment from allied hospital, faisalabad and family polyclinic, faisalabad. mean age and weight was 51 ± 0.78 and 87 ± 5.10 respectively. the average b.m.i for subjects was 29±1. blood glucose conc. after consumption of control cookies showed that increased initially and was maximum at 45 min time interval and after that gradually there was decline till 120min time interval. for t1 and t2 cookies same trend was observed, 45 min after that there was decrease till 120 min. on the other hand, t3, t4 and t5 following the same trend and higher at 60 min then gradually decreased till 120 min (table1). same trend for changes in glucose levels were observed for t8 and t10 doses, however the greatest reduction table 1: blood glucose concentration are taken in mmol/dl laraib imdad et al j aziz fatm med den college january – june 2022; vol. 4, no. 1 28 at 120 min were observed at these doses of bamboo shoot. significant difference in blood glucose levels was noted among the various doses of bamboo shoot doses (p value 0.00) (table 2). table 3: mean, sd and se for glycemic index of various types of cookies treatments mean sd se glucose 100 0 0 t0 79.198 2.742 0.867 t2 75.716 2.325 0.735 t4 72.565 2.278 0.720 t6 69.974 1.781 0.563 t8 67.152 1.785 0.565 t10 64.689 1.378 0.436 table 4: analysis of variance for glycemic index with respect to types of cookies glycemic index sov ss df ms f sig. between groups 8395.995 6 1399.333 371.464 0.00** within groups 237.326 63 3.767 total 8633.321 69 p-value ≤ 0.05 taken significant the results showed in table 3 highest score for g.i for t0 (79.19±2.74) and the lowest for t10 (64.68±1.78). for t2 (75.71±2.32) for t4 the values are (72.56±2.27). the results for analysis of variance in table 4. pertaining to the glycemic index of different treatments of cookies indicated that the glycemic index of cookies significantly different with each other. discussion the concept of taking high fiber diet in correlation with food for lowering the blood sugar levels, reduction in plasma concentration of bad cholesterol along with enhanced gut motility and prebiotic activity should be appreciated and adopt to prevent pre-diabetic condition and providing good blood sugar control in diabetics. this practice should be adopted in our daily lives to avoid risk of metabolic syndromes. our food is a source of essential nutrients, minerals and vitamins, which is a life line for human in growth and development, which also plays a vital role in immunological defense and healing. the concept of taking high fiber diet for good health is a topic of interest among public and researchers. therefore, sometimes it becomes difficult to define whether these fibers or low g.i and or both brings progressive changes in-correlation to a state of healthy or disease conditions. dietary fibers are capable to decrease the digestion of carbohydrates only if it is existing in an insoluble form and stay unaffected while going through gastrointestinal tract. the glycemic load along with glycemic index among various bakery products are different which usually cause different metabolic syndromes including diabetes, so choosing baked food with high fiber content could be beneficial in preventing these metabolic diseases. it is predominantly significant that the slight difference in glycemic index of commonly consumed food and minor variation in reducing plasma glucose levels have been related with a prevention of getting heart diseases, these findings are in correlation with our study.12, 13 a study done on pre-meal consumption of protein fortified dietary fiber and its effects on lowering post prandial glucose level on type ii diabetic patients, their result was similar to our study.14 from this study, it was determined that food supplemented with resistance starch (r.s) has the potential to regulate insulinsensitivity. ingestion of (r.s) aids the postprandial blood sugar levels & regulate secretions of insulin in women after consumed with β glucan. it was apparent drop in incremental area under the curve, consuming food having high β glucan 34% and peak r.s 60%. this shows decreased i.a.u.c for insulin and glucose respectively. these findings are in correlation with our results of bamboo shoots. it was revealed by authors that the soluble-fibers have better effects on decreasing in post-prandial insulin response than the r.s from high amylase cornstarch alone. mixture of r.s and solublefiber indicated that the drop in glycemic response was enhanced.15 foods which possessed with high glycemic index are ingested and absorbed quickly. this could bring toxic impact on plasma glucose balance. plasma glucose levels (mmol/l) become twofold at least for 2 hours after eating meals with high glycemic than that of low caloric diet containing a smaller amount of added sugars. low caloric food stuff have slow and persistent absorption. thus resulted in slight increase and gradual decrease in post prandial blood sugar levels table 2: analysis of variance (anova) for blood glucose concentrations for two hours after food consumption relation to types of cookies and time interval sov ss df ms f sig. model 3601.497 13 277.038 2293 0.00** treatment 16.07 6 2.678 22.168 0.00** time 326.322 6 54.387 450.163 0.00** error 4.349 36 0.121 total 3605.846 49 therapeutic effects of bamboo shoots in diabetic subject j aziz fatm med den college january – june 2022; vol. 4, no. 1 29 without creating harsh peaks and falls, which is usually associated with high glycemic index food.16 these findings are relevant to our study. it was observed that gradual decrease in blood sugar levels after consuming high fiber diet also resulted in decrease ldl levels.17 this also influence blood sugar levels for long term, which tends to lower the curve of insulin resistance in diabetics. these findings favor the results of our study. more dietary fiber intake produce bulk in our gut, control un necessary appetite, lower blood glucose levels and also considered as prebiotics.18 although prebiotic activity was not the parameter of our study but it could open a new pathway to conduct a research on bamboo shoot as a prebiotic. limitation: hence a detailed through study is also advised on molecular levels of bamboo shoots component in lowering post prandial sugar levels. conclusion bamboo shoots are helpful in reducing the random blood glucose levels in diabetic subjects. glycemic control was improving with increasing the dose of bambooshoot in cookies. recommendation: g.i foods is not only a step to reduce the risk of diseases but helps the dietary experts for the formulation of diet plans. conflict of interest: none funding source: none references 1. izzo a, massimino e, riccardi g, della pepa g. a narrative review on sarcopenia in type 2 diabetes mellitus: prevalence and associated factors. nutrients. 2021;13(1):183. doi: 10.1002/2327-6924.12447 2. levy rb, rauber f, chang k, louzada mldc, monteiro ca, millett c, et al. ultra-processed food consumption and type 2 diabetes incidence: a prospective cohort study. clinical nutrition. 2021;40(5):3608-14.doi:10.1002 /2327 6924.12447 3. jenkins dw, jenks a. exercise and diabetes: a narrative review. the journal of foot and ankle surgery. 2017;56(5):968-74. doi: 10.1002/2327-6924.12447 4. nirmala c, bisht ms, bajwa hk, santosh o. bamboo: a rich source of natural antioxidants and its applications in the food and pharmaceutical industry. trends in food science & technology.2018;77:91-9.http//:doi: 10.1002 /23276924.12447 5. santosha o, bajwaa hk, bishtb ms, nirmalaa c. bamboo shoot fortified cookies as a healthy snack. id; 2018. doi: 10.1002/2327-6924.12447 6. wang y, chen j, wang d, ye f, he y, hu z, et al. a systematic review on the composition, storage, processing of bamboo shoots: focusing the nutritional and functional benefits. journal of functional foods. 2020;71:104015. doi: 10.1002/2327-6924.12447 7. li q, fang x, chen h, han y, liu r, wu w, et al. retarding effect of dietary fibers from bamboo shoot (phyllostachys edulis) in hyperlipidemic rats induced by a high-fat diet. food &function.2021;12(10):4696-706.doi:101039/d0fo024 07d 8. wu w, hu j, gao h, chen h, fang x, mu h, et al. the potential cholesterol-lowering and prebiotic effects of bamboo shoot dietary fibers and their structural characteristics. food chemistry. 2020;332:127372. 9. rezapour m, ali s, stollman n. diverticular disease: an update on pathogenesis and management. gut and liver. 2018;12(2):125. 10. gregg ew, cheng yj, srinivasan m, lin j, geiss ls, albright al, et al. trends in cause-specific mortality among adults with and without diagnosed diabetes in the usa: an epidemiological analysis of linked national survey and vital statistics data. the lancet. 2018;391 (10138) :2430-40. 11. herrera mca, subhan fb, chan cb. dietary patterns and cardiovascular disease risk in people with type 2 diabetes. current obesity reports. 2017;6(4):405-13. 12. kasprzak k, wojtunik-kulesza k, oniszczuk t, kuboń m, oniszczuk a. secondary metabolites, dietary fiber and conjugated fatty acids as functional food ingredients against overweight and obesity. natural product communications. 2018;13(8):1934578x1801300836. doi: https://doi.org/10.1177/1934578x1801300836 13. singh j, metrani r, shivanagoudra sr, jayaprakasha gk, patil bs. review on bile acids: effects of the gut microbiome, interactions with dietary fiber, and alterations in the bioaccessibility of bioactive compounds. journal of agricultural and food chemistry. 2019;67(33):9124-38. 14. bae jh, kim lk, min sh, ahn ch, cho ym. postprandial glucose‐lowering effect of premeal consumption of protein‐ enriched, dietary fiber‐fortified bar in individuals with type 2 diabetes mellitus or normal glucose tolerance. journal of diabetes investigation. 2018;9(5):1110-8. 15. higa m, fuse y, miyashita n, fujitani a, yamashita k, ichijo t, et al. effect of high β-glucan barley on postprandial blood glucose levels in subjects with normal glucose tolerance: assessment by meal tolerance test and continuous glucose monitoring system. clinical nutrition research. 2019;8(1):5563. doi: 10.7762/cnr.2019.8.1.55 16. ahuja a, gupta j, gupta r. diabetes silent killer: medical focus on food replacement and dietary plans. adv biores. 2020;11(5):128-35. 17. rivera‐piza a, choi l, seo j, lee hg, park j, han si, et al. effects of high‐fiber rice dodamssal (oryza sativa l.) on glucose and lipid metabolism in mice fed a high‐fat diet. journal of food biochemistry. 2020;44(6):e13231. 18. lambeau kv, mcrorie jr jw. fiber supplements and clinically proven health benefits: how to recognize and recommend an effective fiber therapy. journal of the american association of nurse practitioners. 2017;29(4):216-2 doi: 10.1002/2327-6924.12447 laraib imdad et al https://doi.org/10.1002/2327-6924.12447 https://doi.org/10.1002/2327-6924.12447 https://doi.org/10.1002/2327-6924.12447 https://doi.org/10.1002/2327-6924.12447 https://doi.org/10.1002/2327-6924.12447 https://doi.org/10.1002/2327-6924.12447 https://doi.org/10.1002/2327-6924.12447 https://doi.org/10.1002/2327-6924.12447 http://dx.doi.org/10.1039/d0fo02407d http://dx.doi.org/10.1039/d0fo02407d https://doi.org/10.1177%2f1934578x1801300836 https://doi.org/10.7762/cnr.2019.8.1.55 https://doi.org/10.1002/2327-6924.12447 j aziz fatm med den college january – june 2022; vol. 4, no. 1 30 author’s contribution: laraib imdad study design, approval from advance study and research board, data collection, data analysis, and interpretation and write up for results. manuscript writing, critically revised important intellectual content. dr. m adeel alam shah study design, data analysis. manuscript writing, critically revised important intellectual content. revised and approved the articles. dr. javaid hassan data collection, data analysis, manuscript writing, critically revised important intellectual content. revised and approved the articles dr. farhat humayun data collection, data analysis, manuscript writing, critically revised important intellectual content. revised and approved the articles. dr. ayesha sadiq study design, data analysis and interpretation, revising manuscript critically for important intellectual content. dr. mavish javed data collection, data analysis, manuscript writing, critically revised important intellectual content. revised and approved the articles. all authors are equally responsible for the validity of the data therapeutic effects of bamboo shoots in diabetic subject approved the articles al date of submission: 19-08-2021 revised received: 01-01-2022 accepted: 25-01-2022 j aziz fatm med den college january – june 2022; vol. 4, no. 1 37 original article guy’s stone scoring in predicting postoperative residual stone muhammad waqas iqbal, farhan jamshed, adeen akram, nauman khalid, muhammad saifullah, muhammad akram malik abstract objective: to determine the frequency of postoperative residual stone based on preprocedural guy’s scoring system. methodology: this cross-sectional descriptive study was conducted from1st june 2018 to 30th november 2019 at university medical college faisalabad. all patients with stones in the kidney undergoing pcnl, 20 to 60 years of age of both genders were included. patients with secondary stones due to pelviureteric junction obstruction, crf and recurrent stones were excluded. in all patients guy’s scoring was measured. then all patients underwent pcnl. after 24 hours of operation, ct scan was done in each patient and residual stone (present/abse nt) was noted. results: this study was comprised of 91 patients of age ranged from 2060 years. fifty-three patients (58.24%) were males and 38 (41.76%) females. seven (7.69%) were of guy’s grade i, 48(52.75%) grade ii, 21(23.08%) grade iii and 15 of grade iv. number of patients with residual stone was 09 (9.89%), 0.0% of gs 1, 12.5% of gs 2, 4.76% of gs 3 and 13.33% of gs 4 patients had residual stone. conclusion: pre-pcnl guy’s scoring is easy, rapid and useful for predicting the residual stone after percutaneous nephrolithotomy. keywords: residual stone, guy’s scoring system, extracorporeal shockwave lithotripsy introduction nephrolithiasis is a common disorder with estimated prevalence of 1-13% in various regions of the world.1 precipitating factors of kidney stone disease include age, gender, diet, lifestyle, socioeconomic status, geographical location and race/ethnicity resulting in various incidence rates in different countries.2,3 urinary stone disease has affected mankind since antiquity. it has been even found in egyptian mummies.4 nephrolithiasis is a recurrent disorder. in some studies recurrence rate has been ____________________________________________________________ dr. muhammad waqas iqbal mbbs, fcps assistant professor university medical college, fsd dr. farhan jamshed mbbs, fcps senior registrar university medical college, fsd dr. adeen akram mbbs postgraduate resident (pgr) district headquarter (dhq) hospital, fsd dr. nauman khalid mbbs, fcps assistant professor university medical & dental college, fsd dr. muhammad saifullah mbbs, fcps senior registrar district headquarter (dhq) hospital, fsd dr muhammad akram malik mbbs, fcps professor university medical college, fsd correspondence: dr. muhammad akram malik email: akrammlk@yahoo.com reported from 21% to 53%. most of the stones are of calcium oxalate (75%-90%). other components were uric acid (5%−20%), calcium phosphate (6%−13%) and struvite (2%−15%).5,6 new techniques have been developed for the management of renal stones with the advances in technology in this modern era. extracorporeal shockwave lithotripsy (eswl), percutaneous nephro lithotomy (pcnl), retrograde intrarenal surgery (rirs), and laparoscopic stone surgeries have replaced open surgical procedures in majority of cases.7 percutaneous nephrolithotomy (pcnl) is now consi dered as first line standard treatment for large renal stones >2cm. as the incidence of renal stone is increasing, procedure of pcnl has become increa singly popular. stone free rate after pcnl and its complications are topic of discussion due to increasing number of procedures in the world. the objective and goal of pcnl is the provision of maxi mum stone clearance with minimal rate of compli cations.7 different preoperative factors which affect the outcome of pcnl are size & site of the stone, patient’s characteristics and renal anatomy.8 to date computed tomography (ct) is considered as the most important imaging investigation in renal stones prior to pcnl. ct plays a very important role in preoperative assessment of stone’s characteristics and renal anatomy. various scoring systems like guy’s scoring, croes nomogram and s.t.o.n.e., are based on findings of preoperative ct.9,10 aims of the study was to determine the frequency of j aziz fatm med den college january – june 2022; vol. 4, no.1 38 postoperative residual stone based on pre-procedural guy’s scoring system. methodology it was a descriptive study conducted at university medical college faisalabad from june, 01, 2018 to november, 30, 2019. all patients with kidney stones of either gender, with age range 20-60 years were included into this study. diagnosis was confirmed by plain computerized tomography (ct). ethical approval was taken from ethical approval committee (tuf/dean/2018 dated may, 15, 2018). preoperatively guy’s scoring was done for each patient as follows: guy’s stone score 1 (gss1): a solitary stone in the mid/and or lower pole or in the renal pelvis with a normal anatomy and simple collecting system guy’s stone score 2 (gss2): a solitary stone in the upper pole; multiple stones in patients with simple anatomy; or a solitary stone in a patient with abnormal anatomy guy’s stone score 3 (gss3): multiple stones in a patient with abnormal anatomy or in a calyceal diverticulum or partial staghorn calculus guy’s stone score 4 (gss4): a complete staghorn calculus or any stone in a patient with spinal bifida or a spinal injury, calculus in patients with clinical neurological alternations (spinal cord injury, myelomeningocele) all patients underwent pcnl by experienced consultant. ct-scan was performed on 1st postoperative day to see any residual stone >2mm. patients with secondary stones due to pelviureteric junction obstruction as assessed on computed tomography urography (ctu), of chronic renal failure (s/creatinine >1.5 mg/dl) and with recurrent stones were excluded from study. morbidly obese patients (bmi >37 kg/m2) and the patients in which procedure was converted to open pyelolithotomy were also excluded. statistical analysis: social science (spss) version 20.0 was used to analyze the entered data. quantitative data were presented as mean ± sd. qualitative data were presented as frequency and percentage. preoperative guy’s grading (1/2/3/4) and effect modifiers like age, gender & bmi were stratified. poststratification chi-square was used to assess their effect on postoperative residual stone and p-value ≤0.05 was taken as significant. results total no of patients in this study was 91. age ranged from 2060 years with mean age of 35.64 ± 8.12 years. characteristics of patients according to age, gender and bmi is shown in table 1. male to female ratio was 1.4:1. mean bmi was 27.73 ± 2.86 kg/m2. table 1: characteristics of patients according to age, gender and bmi (n=91) groups no. of patients (n) percentages (%) age 20-40 69 75.82 41-60 22 24.18 gender male 53 58 female 38 42 bmi (kg/m2) ≤27 44 48.35 >27 47 51.65 fifty three patients (58.24%) were males and 38 (41.76%) females. male to female ratio was 1.4:1. mean bmi was 27.73 ± 2.86 kg/m2 (table i). mean preoperative guy’s grading was 2.48 ± 0.86. distribution of patients according to preoperative guy’s grading is shown in (figure 1). figure 1: distribution of patients according to pre-operative guy’s grading (n=91). gss=guy’s stone score residual stone was present in 09 (9.89%) with none in grade 1 and 2(15.38%) in grade 4(table 2). 0 10 20 30 40 50 60 gss1 gss2 gss3 gss4 7(7.69%) 48(52.75%) 21(23.08%) 15(16.48%) p e rc e n ta g e s muhammad waqas iqbal et al j aziz fatm med den college january – june 2022; vol. 4, no.1 39 table 2: stratification of residual stone with respect to pre-operative guy’s grading (n=91). pre-operative guy’s grading residual stone p-value present n (%) absent n (%) grade 1 00 7 (100) 0.582 grade 2 06 (12.5) 42 (87.5) grade 3 01 (4.7) 20 (95.2) grade 4 02 (13.3) 13 (86.6) p-value ≤0.05 taken as significant. stratification of residual stone with respect to age, gender and bmi shows greater number of residual stones in age group of 41-60 years (table 3). table 3: stratification of postoperative residual stone with respect to age, gender and bmi groups (n=91). groups residual stone p-values present n absent n age 20-40 04 65 0.021* 41-60 05 17 gender male 04 49 0.377 female 05 33 bmi (kg/m2) ≤27 06 38 0.247 >27 03 44 p-value ≤0.05 taken as significant. discussion percutaneous nephrolithotomy (pcnl) is being considered as procedure of choice for large and complex renal calculi and has replaced the open surgical procedures to greater extent.11although pcnl is an endoscopic procedure with higher success rate and minimal complications, however stone free rate is not 100%.12stone size, burden, and location, renal calyceal anatomy and associated hydronephrosis are different parameters which predict the outcome of pcnl. however, when these parameters are used individually, precise outcome of the procedure cannot be predicted.13 due to this reason various scoring systems have been invented to predict the outcome of pcnl. these scoring systems are based on preoperative stone size/burden, renal calyceal anatomy and patient's characteristics (age/ gender/body built/bmi).14 besides prediction of stone free rate, counseling of patient, refinement of procedure and adjustments of various training programs can be managed by these scoring.15 various scoring systems have been developed to predict stone free rate and complications. guy’s scoring system, the s.t.o.n.e. scoring system, the s-resc scoring system of the seoul national university and the croes, are among the most commonly applied and evaluated. guy’s scoring is easy to perform, simple and rapid to predict the outcome of pcnl.16-19 in our study, the percentage of patients with residual stone was 09 (9.89%). 0.0% of gs 1, 12.5% of gs 2, 4.76% of gs 3 patients and 13.33% of gs 4 had residual stone. in a study, 75% of the subjects were gs 1, 21% gs 2 and 3% gs 3. in this study, 66% of gs 3, 4% of gs 2 and 10% of gs had residual stone. 20another published series reported residual stones in 70% of gs 1, 65% of gs 2 and 38% of gs 3 persons.21 results of our study are comparable with these studies, however with better outcome in present study. vicentini et al reported rates of 95% and 79 %, 59 % and 41% of stone-free patients in gs1, gs2 gs 3 and gs 4 scoring system respectively in their series involving 147 pcnl patients , and elaborated a significant association of guy scores and stone-free rate.13 kay thomas evaluated residual stones in 100 patients who underwent pcnl, and found residual stones in 19% of grade i, 28% of grade ii, 65% of grade iii and 71% of grade iv.18 results obtained by kay thomas and vicentini et al are contradictory to the study conducted by mandal et al19, who found stone free rate of 0%, 56%, 68%, 74%, for grade 1-4 respectively. as reported in all above mentioned series, guy’s scoring system precisely discriminates between the two endpoints. guy’s scoring system briefly creates two group of grades, good and bad. grades 1 and 2 are considered as good and grades 3 and 4 are relatively bad group. our study has age range from 20 60 years (mean = 35.64 ± 8.12 years). as the age and clearance of renal stone is concerned there is significant difference in terms of residual stone among two age groups. 29% of patients in age group 41-60 have residual stone as compared to 6% in age group 20-40 years(p-<0.021). in a study conducted by rahul gupta there is no difference in different age groups as far as stone free rate is considered (94% vs 92% respectively in older & young).22 most probable causative factor for higher residual stone in the older age group in our study is obesity.23 no statistically significant difference in terms of residual stone with respect to gender (8% in male and 13% in female) and weight (14% in bmi ≤27 and 6% in bmi >27). these results are comparable to other series.23, 24 the guy score has been validated externally in a large number of published series. in two separate series by mandal and ingimarsson, guy’s scoring system effectively predicted sfr and has been externally validated.19,25 the guy score has excellent interobserver reliability.25 guy’s scoring for residual stone j aziz fatm med den college january – june 2022; vol. 4, no.1 40 conclusion pre-pcnl guy’s is useful for predicting the residual stone after the procedure. we recommend that this scoring system can be applied routinely in patients undergoing pcnl for pre-operative evaluation of surgical outcome so that patients can be counseled preoperatively for chances of residual stone. disclaimer: this study was a part of dissertation for fcps part ii, a mandatory requirement of eligibility to appear in examination. conflict of interest: none funding source: none references 1. sorokin i, mamoulakis c, miyazawa k, rodgers a, talati j, lotan y. epidemiology of stone disease across 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metaanalysis. bmc urol 2019 19, 57 doi:10.1186/s12894-019-0488-y 11. mak dk, smith y, buchholz n, el-husseiny t. what is better in percutaneous nephrolithotomy prone or supine? a systematic review. arab j urol.2016;14:101-107.doi:10.1016/j.aju.2016.01.005 12. jeong cw, jung jw, cha wh, lee bk, lee s, jeong sj, et al. seoul national university renal stone complexity score for predicting stone-free rate after percutaneous nephrolithotomy. plos one. 2013;18(6);e0065888.doi: 10.1371/journal.pone.00658 88 13. vicentini fc, marchini gs, mazzucchi e, claro jf, srougi m. utility of the guy's stone score based on computed tomographic scan findings for predicting percutaneous nephrolithotomy outcomes. urology 2014;83:1248-1253.doi:10 .1016/j.urology.2013.12.041 14. choi sw, bae wj, ha us, hong sh, lee jy, kim sw, et al. prediction of stone-free status and complication rates after tubeless percutaneous nephrolithotomy: a comparative and retrospective study using three stone-scoring systems and preoperative parameters. world j urol 2017 35(3):449-457. doi: 10.1007/s00345-016-1891-6 15. omer rashid a, khalid h, friad g, hamed r, y, buchholz n: guy’s stone score as a predictor for stone-free rate and complications in percutaneous nephrolithotomy: a singlecenter report from a stone belt country. urol int 2020;104:746-751. doi: 10.1159/000506211 16. m. khalil, h. sherif, a mohey r. omar. utility of the guy’s stone score in predicting different aspects of percutaneous nephrolithotomy, afr j u, 2018,24,3,,191-196.doi:10.1016/j. afju .2018.06.005 17. okhunov z, friedlander ji, george ak, duty bd, moreira dm, srinivasanak,etal.s.t.o.n.e. nephrolithometry: novel surgical classification system for kidney calculi. urology .2013; 81:11541159. doi: 10.1016/j.urology.2012.10.083 18. thomas k, smith nc, hegarty n, glass jm. the guy’s stone score--grading the complexity of percutaneous nephrolithotomy procedures. urology 2011;78:277-281.doi: 10.1016 /j.urology .2010.12.026 19. mandal s, goel a, kathpalia r, sankhwar s, singh v, sinha rj, etal. prospective evaluation of complications using the modified clavien grading system and of stone free rates of percutaneous nephrolithotomy using guy's stone score: a single-center experience. indian j urol 2012; 28:392-8. doi: 10.4103/09701591.105749. 20. kumsar s, aydemir h, halis f, köse o, gökçe a, adsan o. value of preoperative stone scoring systems in predicting the results of percutaneous nephrolithotomy. cent european j urol.2015;68: 353-357. doi: 10.5173/ceju.2015.552 21. labadie k, okhunov z, akhavein a, moreira dm, morenopalacios j, del junco m, et al. evaluation and comparison of urolithiasis scoring systems in percutaneous kidney stone surgery.jurol.2015;193:154-159. 22. gupta r, mahajan a. outcomes of percutaneous nephrolithotomy in elderly versus young patients under regional anesthesia: a comparative study. urol ann. 2020;12(3):254-258. doi: 10 .4103/ ua.ua_69_19 23. abdrabuh, a.m. impact of weight on stone-free rate during percutaneous nephrolithotomy. afr j urol, 2020;26,65.doi: 10. 1186/s12301-020-00071-4 24. immad mi, jabbour t zgheib j. prone pcnl: safety and efficacy in obese and morbidly obese patients. urol nephrol open access j. 2018;6(3):84-88. doi: 10.15406/unoaj.2018.06.00209 25. ingimarsson jp, dagrosa lm, hyams es. external validation of a preoperative renal stone grading system: reproducibility and inter-rater concordance of the guy’s stone score using preoperative computed tomography and rigorous postoperative stone-free criteria. urology. 2014;83(1):4549.doi: 10.1016/j.urology.2013.09.008 muhammad waqas iqbal et al https://doi.org/10.1007/s00345-017-2008-6 https://doi.org/10.1007/s00345-018-2562-6 https://dx.doi.org/10.4103%2f0974-7796.152927 https://dx.doi.org/10.1016%2fj.ajur.2018.08.007 http://www.ncbi.nlm.nih.gov/pubmed/?term=skolarikos%20a%5bauthor%5d&cauthor=true&cauthor_uid=25454613 http://www.ncbi.nlm.nih.gov/pubmed/?term=t%c3%bcrk+c%2c+knoll+t%2c+petrik+a%2c+sarica+k%2c+skolarikos+a%2c+straub+m%2c+et+al.+guidelines+on+urolithiasis.+arnhem+(the+netherlands)%3a+european+association+of+urology+(eau)+2013 https://doi.org/10.1016/j.eururo.2014.10.029 https://doi.org/10.1111/bju.13848 https://doi.org/10.1111/bju.13848 https://doi.org/10.1089/end.2015.0700 https://dx.doi.org/10.1016%2fj.aju.2016.01.005 https://dx.doi.org/10.1371%2fjournal.pone.0065888 https://dx.doi.org/10.1371%2fjournal.pone.0065888 https://doi.org/10.1016/j.urology.2013.12.041 https://doi.org/10.1016/j.urology.2013.12.041 https://doi.org/10.1007/s00345-016-1891-6 https://doi.org/10.1159/000506211 https://doi.org/10.1016/j.afju.2018.06.005 https://doi.org/10.1016/j.afju.2018.06.005 https://doi.org/10.1016/j.urology.2012.10.083 https://doi.org/10.1016/j.urology.2010.12.026 https://doi.org/10.1016/j.urology.2010.12.026 https://dx.doi.org/10.5173%2fceju.2015.552 https://dx.doi.org/10.4103%2fua.ua_69_19 https://dx.doi.org/10.4103%2fua.ua_69_19 https://doi.org/10.1186/s12301-020-00071-4 https://doi.org/10.1186/s12301-020-00071-4 https://doi.org/10.1016/j.urology.2013.09.008 j aziz fatm med den college january – june 2022; vol. 4, no.1 41 authors’ contribution: dr. m. waqas iqbal study design, manuscript writing. revised and approved the articles. study design, acquisition of data and manuscript writing. revised and approved the articles dr. farhan jamshed study design, acquisition of data and manuscript writing. revised and approved the articles dr. adeen akram study design, acquisition of data, data analysis and interpretation and write up of results dr. nauman khalid data analysis and interpretation and write up of results approve the final version of article. dr. m. saifullah study design. revising manuscript critically for important intellectual content and approve the manuscript dr. m. akram malik study design, critically revising manuscript critically for important intellectual content and approve the manuscript all authors are equally accountable for research work and integrity date of submission: 10-04-2021, revised received: 16-12-2021, accepted: 22-01-2022 guy’s scoring for residual stone j aziz fatm med den college january – june 2022; vol. 4, no. 1 22 original article frequency of myopia in school going students of rural and urban areas of sahianwala and chiniot, punjab shakila abbas, nimra gul, ayesha kiran, komal shahzadi abstract objective: to find the frequency of myopia in rural versus urban primary and secondary school going students from 6 to 16 years of age. methodology: a school based cross sectional study was conducted from august to december 2021 in rural area of sahianwala, and in urban area of chiniot region. the study was approved by ethical review board of the university of faisalabad. a total of 1000 subjects of both gender and ages ranged between 6 to 16 years were included through a stratified random sampling technique. the sample consist a set of 500 subjects each from rural and urban areas. subjects of 1st class to 10th class were selected. data was collected using a proforma and retinoscopy was done for diagnosis of myopia. data was analyzed by using chi-square test in spss 20 software. results: the frequency of myopia was higher in urban area 41.6% than rural area 28% (p 0.00). other findings included a frequency of emmetropia of (42.6%) in urban in comparison to (56.6%) in rural areas. other types of refractive errors including hypermetropia and astigmatism were (15.8%) in urban and (15.4%) in rural area. myopia was more among female 39.6% than male 30% (p value= 0.00). frequency of myopia was more in high level 35.5% than primary 34.8% and middle 34.0% level education (p value= 0.04). conclusion: the frequency of myopia is higher in students of urban schools as compared to rural schools myopia is more frequently found in females as compared to male students. keywords: emmetropia, myopia, retinoscopy, visual problems. introduction vision is essential to carry out daily activities of life and to move in society.1 perfect vision is the result of parallel rays of light coming from infinity and sharply focused on sensitive layer of eye; with the lens in a relaxed state. a condition where the corneal dioptric power and axial length of the eyeball balance out, this condition is called emmetropia.2 when these rays of light do not fall on retina, the condition is called ametropia, includes myopia, hypermetropia and astigmatism. refractive error cause blurry vision. it is frequently categorized as spherical and cylindrical error. when the dioptric power is too little or too much then the rays of light are focused behind or in front of the retina, respectively. these are called spherical errors. when a person sees lines of particular orientation ____________________________________________________________ shakila abbas1 od, mphil lecturer nimra gul2 od, mphil lecturer ayesha kiran3 od, mphil lecturer komal shahzadi4 od clinical optometrist 1-4the university of faisalabad correspondence: dr. shakila abbas email: shakila.abbas@tuf.edu.pk less clearly then lines at right angle to that meridian it is called cylindrical error.3 people with such condition cannot see clearly and different ophthalmic lenses are required to correct this condition.4 myopia, also called nearsightedness is the most common type of ammetropia, in which light coming from infinity are focused in front of the retina, with patient’s accommodation relaxed. myopia is also defined as increased refractive power of the eye due to either increase in axial length of the eyeball, curvature of the cornea or refractive index of lens. so, myopic patient sees near objects clearly and feels difficulty to look at distant objects. uncorrected refractive error is a common cause of visual problems.5both environmental and hereditary factors are crucial risk factors for myopia development. in genetics myopia may present with certain heritable connective tissue disorders and has also been reported as an x-linked disorder. increased reading hours, higher level of education and low/high socioeconomic status are also the risk factors for myopia.6 numerous environmental factors contribute to progression of myopia such as amount of near work performed. near work is defined as any activities that require accommodation of a lens to focus clear images on the retina such as reading, studying (doing homework and writing), playing video games, using computers, or watching television. as more near mailto:shakila.abbas@tuf.edu.pk j aziz fatm med den college january – june 2022; vol. 4, no. 1 23 work is performed; it increases chances to develop myopia.7 based on recent studies, myopia in children is associated with both genetic and environmental factors such as near work and outdoor activities.8 it is evident a student who spends more time in near work and reduces outdoor activities, reading in supine position more prone to rapid progression in myopia.9 myopia is more frequently developing in school going children in this era of modern technology and of growing increase in the use of electronic screens including, computers and smart mobile phone during online classes and for playing video games and watching cartoons and drama frequently.8,9 myopia may divide into three types according to the degree of severity such as low myopia, medium myopia and high myopia. low myopia is < 3 d, medium 3-6 d and high is > 6 d. myopia may also be classified based on fundus changes, e.g. simple or physiological myopia and pathological or degenerative myopia. the main problem of myopic children is that distant objects are blurry or unclear such as the white board or blackboard. during watching television or using a computer uncorrected myopic child usually sit close to the screens for clear vision that further progresses the myopia. difficulty in reading and studying due to poor eye sight will compromise their studies as well as quality of lives and will face difficulty in coping with other students.10 myopia is manageable and there are various treatment options are available to correct myopia such as corrective lenses, surgical and non-surgical ways. corrective lenses included both glasses and contact lenses. in surgical procedure, a laser is used to modify corneal curvature, so it brings light to focus on the retina.11 this study was aimed to screen the students with refractive errors especially for myopia. if this condition is screened early in life it will be easily manage and treated thereby help to halt the progression of disease. hence, in this way it will also help for better performance in their education. methodology a school-based cross-sectional study was conducted from august to december 2021 at rural area of sahianwala and urban area of chiniot regions. the study was approved by ethical review board of the university of faisalabad (tuf/irb/006/2021). school going students from class 1 to class 10th aging from 616 years old were screened for myopia. all the students from 1st class to 10th class without any known ocular pathologies were included in the study. formal permission was taken from the principle of these schools. the inclusion criteria of this study were children with any problems in seeing white boards, watching tv and distance blurred vision. students with ocular pathologies e.g. keratoconus, strabismus were excluded from this study. the sample was selected using stratified random sampling technique. three groups of classes were made, including primary, middle and high in which students ranging from class 1 to 5th, 6 to 8th and 9 to10th were examined. thus a total sample of 1000 students was taken through empirical approach in which male and female, both are equally divided including 500 males and 500 females. the sample consisted of 500 subjects in rural and 500 subjects in urban schools. the children's parents gave the consent and completed a detailed questionnaire that included each child's demographics, the use of electronic devices and other related risk factors. objective refraction with streak retinoscope (heine model number beta 200) was done. history was taken from each student particularly for any problem in seeing white boards, watching tv and distance blurred vision. before performing dry retinoscopy a distant large target was given to children on a wall and they were asked to maintain steady fixation. retinoscopy method which was done is as follows: in dim light room children were seated in front of retinoscope and arm’s length distance was maintained by asking the children to look at a fixation target for relaxing his accommodation. the child’s right eye was examined with observer right eye, right hand and vice versa with the child both eyes opened. the retinoscopy is performed at 67cm distance. then by turning on retinoscope light and shown into child eye while his other eye was opened, the reflex which was observed have the following characteristics. in case of myopia against movement of the reflex was seen. in case of hypermetropia with motion of reflex was seen. in case of emmetropia no red reflex was seen instead a fully illuminated pupil was seen. statistical analysis: after the collection of data, data were analyzed with the help of ibm spss-20 version to get a statistical result. the descriptive statistics were presented in the form of frequencies and percentages. chi-square test was used and a p-value <0.05 is taken as significant. results the numbers of total subjects examined in rural and urban school were 1000. out of 1000 students, 496 (49.6%) were emmetropic, 339(33.9%) myopic and with other types of refractive error 165 (16.5%). table 1 is showing comparison of frequencies of refractive error among the students of urban and rural shakila abbas et al j aziz fatm med den college january – june 2022; vol. 4, no. 1 24 schools. higher frequency of myopia was noticed among the students of urban areas. chi-square was used to compare the frequency of myopia which showed significant p-value = 0.00. table 1: comparison of frequency of myopia in urban and rural areas (n=500 rural, 500 urban) variable emmetropia myopia others ** p value frequency (%) frequency (%) frequency (%) urban 213 (42.6%) 208 (41.6%) 79 (15.8%) 0.00* rural 283 (56.6%) 140 (28%) 77 (15.4%) * p value <0.05 is considered as significant. **hypermetropia, astigmatism equal number of males and females were examined. greater number of males were emmetropic than female. other types of refractive errors include hypermetropia and astigmatism is more in males than females. the frequency of myopia is more in females as compared to males are described in (table. 2). the results are significant against the p value of 0.006. table 2: comparison of frequency of myopia according to gender & class level (n=1000) variable emmetropia myopia other** p value frequency (%) frequency (%) frequency (%) male (n=500) 276 53.4% 150 30% 74 14.8% 0.006 female (n=500) 229 45.8% 198 39.6% 73 14.6% primary (n=359) 170 47.3% 125 34.8% 64 17.8% 0.044 middle (n=332) 159 47.8 113 34% 60 18% high (n=309 167 54% 110 35.5% 32 10.3% * p value <0.05 is considered as significant. **hypermetropia, astigmatism the 1000 subjects were examined which are divided into three class levels primary (1 to 5th), middle (6 to 8th) and high (9 to 10th). the result of this study shows that there is higher frequency of myopia in higher level as compared to primary and middle is described in (table 2). the results are significant with p value 0.044. discussion about 285 million people are visually impaired worldwide, 36 million are blind and 216.6 million have low vision.12 visually impaired people are 41.8% due to a major cause of refractive error. visual impairment from uncorrected refractive errors can have long term effects in children and adults including loss of education and impaired quality of life.13 the factors which are responsible for uncorrected refractive errors are lack of education and awareness, resources including money problem and unavailability of health care facilities. therefore, screening of children of primary level is very important to know about frequency of myopia and give proper education and correction including spectacles at time. according to present study the frequency of myopia was 33.9%. the frequency of emmetropia and other refractive error including hyperopia and astigmatism was 49.6% and 16.5%. contradictory to our finding, the study conducted at iran documented lower prevalence of myopia, hyperopia.14 lower prevalence of refractive errors were also reported from previous researches of in malaysia, and iran was 7.7%, and 3.5%. however higher prevalence of myopia affecting >1/2 of children was reported from china and singapore.15 higher prevalence of myopia were also reported from nepal, affecting 3.5% of children.16 in current study we found lower frequency of myopia among the students of rural school as compared to urban areas (28% vs. 41.6 %). our results are in line with previous studies that also showed that lower prevalence of myopia in rural school children as compared to urban schools our results are also in accordance with the study conducted in nepal that reported only <3% prevalence of myopia in children of rural area and 27.3 % in student of urban area schools.17 the most probable reason of myopia in children are might be due to, less time spent at outdoor activities, playing games on smart phone, using computer and more near work activities reading and writing. in this study we interestingly found significantly higher frequency of myopia in high school students, followed by primary school children while lowest frequency was found in middle school children. our results are in accordance with study performed at eastern china that also reported high prevalence of myopia in higher school students.18 however, in contrast to this previous studies in saudi arabia have reported high prevalence of refractive error in middle school going children.19 current results also revealed that females students were more frequently found to be myopic than the male counterparts and this may be attributed to spending more time in reading and writing as they are more conscious about their studies. it is necessary to established screening programs at primary school level and proper medical facilities should be available. proper guidance should be given to children; teachers and parents so if they recognize any problem in vision then immediately go for refraction. limitations: no casual inferences are established due to cross sectional study. frequency of myopia in school going students j aziz fatm med den college january – june 2022; vol. 4, no. 1 25 conclusion frequency of myopia was higher in urban school going students. myopia was comparatively higher among female students as compared to male counterparts. effective strategies are needed to eliminate the cause of significant visual problems. funding source: none conflicts of interest: none references 1. adigun k, oluleye ts, ladipo mma, olowookere sa. quality of life in patients with visual impairment in ibadan: a clinical study in primary care. j multidisciplinary healthcare. 2014; 7: 173-178. doi: 10.2147/jmdh.s51359 2. khurana ak. errors of refraction and binocular optical defects. theory and practice of optics and refraction. 2nd ed. india: elsevier; 2008. p. 61-62. 3. parrey mu, elmorsy e. prevalence and pattern of refractive errors among saudi adults. pakistan journal of medical sciences. 2019; 35(2): 394-398. doi: 10.12669/pjms.35.2.648 4. cooper j, tkatchenko av. a review of current concepts of the etiology and treatment of myopia. eye & contact lens. 2018; 44(4): 231-247. doi: 10.1097/icl.0000000000000499 5. belete gt, anbesse dh, tsegaye at, hussen ms. prevalence and associated factors of myopia among high school students in gondar town, northwest ethiopia. clinical optometry. 2017; 9: 11-18. doi: 10.2147/opto.s120485 6. theophanous c, modjtahedi bs, batech m, marlin ds, luong tq, fong ds. myopia prevalence and risk factors in children. clinical ophthalmology(auckland,nz).2018;12:1581-1587.doi:10.2147 /opth.s164641 7. williams km, bertelsen g, cumberland p, wolfram c, verhoeven vjm, anastasopoulos e, et al. increase prevalence of myopia in europe and the impact of education. american academy of ophthalmology.2015;122(7):1489-1497 8. liu s, ye s, xi w, zhang x. electronic devices and myopic refraction among children aged 6-14 years in urban areas of tianjin, china. ophthalmic physiol opt. 2019 jul;39(4):282-293.doi:10.1111/opo. 12620 9. wu pc, huang hm, yu hj, fang pc, chen ct. epidemiology of myopia. the asia-pacific journal of ophthalmology. 2016; 5(6): 386393. doi: 10.1097/apo.0000000000000236 10. lingham g, mackey da, lucas r, yazar s. how does spending time outdoors protect against myopia? a review. british journal of ophthalmology.2020;104(5):593-599.http://dx.doi.org/10.1136/bjop htha lmol-2019-314675 11. wildsoet cf, chia a, cho p, guggenheim ja, polling jr, read s, et al. imi–interventions for controlling myopia onset and progression report. investigative ophthalmology & visual science. 2019;60(3): m106-31. doi:https ://doi.org/ 10.1167 /iovs.18-25958 12. bourne rr, flaxman sr, braithwaite t, cicinelli mv, das a, jonas jb, et al. magnitude, temporal trends, and projections of the global prevalence of blindness and distance and near vision impairment: a systematic review and meta-analysis. the lancet global health. 2017; 5(9): e888-97. https://doi.org/10.1016/s2214-109x(17)30293-0 13. hashemi h, khabazkhoob m, saatchi m, ostadimoghaddam h, yekta a. visual impairment and blindness in a population-based study of mashhad, iran. journal of current ophthalmology. 2018; 30(2): 161168. https://doi.org/10.1016/j.joco.2017.01.003 14. hashemi h, nabovati p, yekta a, shokrollahzadeh f, khabazkhoob m. the prevalence of refractive errors among adult rural populations in iran. clinical and experimental optometry. 2018; 101(1): 84-89. https://doi.org/10.1111/cxo.12565 15. mingguang h, yingfeng z, fan x. prevalence of myopia in urban and rural children in mainland china. optometry and vision science. 2009; 86(1): 40-44. doi: 10.1097/opx.0b013e3181940719 16. awasthi s, pant bp, langaas t. refractive error prevalence among school children in dadeldhura district of nepal. kathmandu universitymedicaljournal.2020;18(2):46-51.doi.org /10.3126/ kumj .v18i2.33225 17. norouzired r, hashemi h, yekta a, nirouzad f,ostadimoghaddam h, yazdani n, et al. the prevalence of refractive error in 6to 15-yearold school children in dezful, iran. journal of current ophthalmology. 2015; 27(1-2): 51-55. https://doi.org/10.1016/j.joco.2015.09.008 18. wang j, li y, zhao z, wei n, qi x, ding g, et al. school-based epidemiology study of myopia in tianjin, china. international ophthalmology.2020;40:2213-2222.https://doi.org/10.1007/10792 020-01400-w 19. hung hd, chinh dd, van tan p, duong nv, anh nq, le nh, et al. the prevalence of myopia and factors associated with it among secondary school children in rural vietnam. clinical ophthalmology (auckland, nz). 2020; 14: 1079-1790. doi: 10.2147/opth.s251218 date of submission: 07-08-2021 revised received: 11-09-2021, accepted: 15-09-2021 authors’ contribution: shakila abbas concept, study design, data collection, literature search, analysis, first draft writeup nimra gul study design, data collection, literature search, second draft write up ayesha kiran data analysis, final review, overall supervision komal shahzadi data analysis, revised and approved the article all authors are equally responsible for the validity of the data shakila abbas et al j aziz fatm med den college july december 2021; vol. 3, no. 2 56 original article role of white blood cell count in diagnostic accuracy of acute appendicitis sarwat bibi, khurram saqib, muhammad saleem, aalia jadaan, humaira ahmad, hamza rana abstract objective: to assess the role of white blood cell count (wbc) in the diagnosis of acute appendicitis and its relation to histopathological findings. methodology: a descriptive cross sectional study was conducted at aziz fatimah hospital faisalabad. one hundred patients with acute appendicitis were encompassed in our work. diagnosis was confirmed after careful clinical assessment aided with classical sign and symptoms. white blood cell count of every patient was done from laboratory of our hospital. specimen of appendix of every patient was sent for histopathology. in addition, pre-operative white blood cell count (wbc) was compared with postoperative histopathology reports to assess wbc count's significance in the identification of acute appendicitis. results: out of 100 cases, 63 were male, and 37 were females. age of the patients was between 12 to 55 years, mean age being 20.9 years. commonest age group was 17 to 30 years (n=73). the sensitivity and specificity of wbc count were calculated 27% and 43.75% respectively, while positive and negative predictive value was 71.87 and 10.1%, respectively. mean ± sd of tlc of patients with normal and inflamed appendix was 10781±291.0 and 95908 ± 329.43respectively, this difference was not statistically different (p value=0.16). neutrophils count was 66. 86% in patients with inflamed appendix and nearly equal to this 65.18% was noticed with normal appendix on histopathology (p value=0.15). odd ratio were insignificant showing wbcs are nor independent predictors of acute appendicitis (p value 0.30) conclusion: white blood cell count is not a very good and reliable investigation for diagnosis of acute appendicitis. patient can be having acute appendicitis with normal white blood cell count. keywords: white blood cells, acute appendicitis, introduction acute appendicitis is one of the frequently seen surgical conditions that present as acute abdomen and needs surgery on emergency basis. it is true that it is a dr. sarwat bibi, mbbs, fcps associate professor aziz fatimah hospital, fsd dr. khurram saqib, mbbs, fcps senior registrar dhq fsd dr. m. saleem, mbbs, fcps associate professor aziz fatimah hospital, fsd dr. aalia jadaan, mbbs, fcps associate professor aziz fatimah hospital, fsd dr.humaira ahmad mbbs, fcps associate professor dhq hospital, fsd hamza rana final year medical student, aziz fatimah medical & dental college correspondence: dr. sarwat bibi email: amerbail18@gmail.com very frequent disease presenting in every surgical emergency, even then its diagnosis becomes a challenge for the surgeons. it is reported that acute appendicitis is wrongly diagnosed in 20-40 % of patients. and a delay in diagnosis can result in many complications like perforated appendix, appendicular abscess, and appendicular mass, localized or generalized peritonitis leading to septicemia and adhesions in abdomen.1 it is commonly seen between 7-15 years of age but it can affect the patients of any age. acute appendicitis is largely diagnosed on basis of clinical evaluation. this include history of usual symptoms (migratory pain, nausea/vomiting and anorexia) and performance of clinical signs in abdomen such as tenderness in right lower quadrant (mcburney's point), rebound tenderness, elevated temperature. the laboratory tests are not persistent and their value in diagnosis of disease is a question mark, chiefly the leukocyte count and c-reactive protein (crp), which are though sensitive but are not very specific for acute appendicitis. however, a combination of both tests in addition to signs and symptoms seems to improve their specificity significantly.2,3 though biomarkers and radiological mailto:amerbail18@gmail.com j aziz fatm med den college july december 2021; vol. 3, no. 2 57 investigations are important adjuncts to history and clinical examination, their limitations show that clinical evaluation of patient is still the mainstay of diagnosis.4 a clinical classification is used to decide management based upon simply inflamed appendix and complicated (gangrenous or perforated) appendicitis. still many patients present with equivocal signs and symptoms, which is one of the most challenging dilemma for surgeons.5 an appendectomy performed on the basis of clinical diagnosis for a suspected appendicitis and it turns out to be normal appendix on the histo-pathological examination, is labeled as negative appendectomy. a negative appendectomy has a risk of postoperative complication rate of around 10%, so it is very important to correctly diagnose it in time.6 patients in whom diagnosis of acute appendicitis is established are largely treated depending upon clinical history and clinical findings of patients on examination; the significance of laboratory tests is still a controversy. different studies have evaluated the role of certain inflammatory markers like total leukocyte count, granulocytes, c reactive proteins, interleukin 6, d lactate, leukocyte elastase activity and phospholipase activity that can help to confirm the diagnosis of acute appendicitis.7 without the help of laboratory and radiological investigations, sometimes it gets very difficult to make a definite diagnosis of acute appendicitis. white blood cell count is one of the laboratory investigation that may help in diagnosis. that’s why it is being assessed in the studies.8 leukocytes are the main cells responsible for the host defense in the presence of various pathogens in the body. they are further divided into phagocytic cells and non-phagocytic cells. phagocytic cells include neutrophils, eosinophils and monocytes. non phagocytic cells include lymphocytes and basophils. these cells release certain immunoregulatory cytokines that play an important role in humeral and cellular immunity. 9 younger age (≤15 years), normal total leukocyte count, computed tomography grade of less than 3 and appendix diameter of less than 6 mm on computed tomography are found to be independent predictive factors for negative appendectomy.10 we conducted the study to evaluate significance of white blood cell count if it can help in aiding the clinical diagnosis of acute appendicitis. methodology it was descriptive, cross sectional study conducted at surgical department of aziz fatima trust hospital in a period of 15 months ranging from 18tht jan 202031st mar 2021. we included 100 consecutive patients who has clinical diagnosis of acute appendicitis as a part of our study. prior to study ethical approval was taken from institutional ethical committee (iec-886-20). patients above 12 years of age of both gender, and were clinically diagnosed as acute appendicitis based upon signs and symptoms and afterward underwent appendectomy were included in the study. patients with acute appendicitis typically had complains of persistent pain in paraumblical or epigastric region that shifted to right iliac fossa and confined at mcburney' s point (at junction of medial 2/3 and lateral 1/3 of a line joining umbilicus and anterior superior iliac spine. associated symptoms were nausea, anorexia and vomiting. on deep palpation, there was tenderness and rebound tenderness. selected patients had positive obturator and psoas tests but abdominal signs were minimal indicating position of the appendix in pelvis. patients who had appendicitis in pregnancy, immunocompromised and those with other acute inflammatory diseases or preexisting infections were excluded from our study. interval appendicectomy was also excluded from the study. informed written consent was taken from each patient for open appendectomy. blood samples were taken before surgery and sent to laboratory of aziz fatima hospital for leukocyte count. reference range for tlc was taken as 4,50011,000 wbcs/µl.11 tlc > 11,000 wbcs/µl considered leukocytosis neutrophil count >75% considered neutrophilia. specimen of appendix was sent to laboratory of aziz fatimah hospital for histopathological examination. microscopic findings of remarkable penetration of mucosa and muscular layer with polymorphonuclear neutrophils, ulceration of epithelium and crypt abscess formation were considered as confirmation of acute appendicitis. preoperative white blood cell count (wbc) was compared with postoperative histopathology report of specimen. statistical analysis: data was analyzed by spss22. quantitative data is presented as mean and standard deviation. intergroup comparison of normally distributed quantitative parameters was done by the student’s t-test .qualitative data is expressed as frequencies and percentages and compared using the chi-square test. binomial logistic regression model was used to investigate whether wbcs are independent risk factor for acute appendicitis or not. results of binomial logistic regression are presented as odd ratio (or) and 95% ci. sensitivity and specificity of wbc count test was estimated. p level ≤0.05 was considered statistically significant. sarwat bibi et al https://www.sciencedirect.com/topics/medicine-and-dentistry/postoperative-complication https://www.sciencedirect.com/topics/medicine-and-dentistry/postoperative-complication https://www.sciencedirect.com/topics/medicine-and-dentistry/computer-assisted-tomography j aziz fatm med den college july december 2021; vol. 3, no. 2 58 results of the 100 patients included in study, 63 (63%) were females while 37 (37%) were male patients. age range was 12 to 55 years. table 1: pre -operative physical findings of patients on clinical examination (n=100) physical findings percentage pain in right iliac fossa 100% anorexia 92% nausea/ vomiting 89% fever 42% tenderness 97% rebound tenderness 74% physical findings of patients on examination were presented in table1. out of total 100 patients total leukocyte count was raised just in 32% and it was normal in 68 % of the patients. neutrophilia was noticed in only 35% of the all patients (table 2). mean ± sd of tlc of patients with normal and inflamed appendix was 10781±291.0 and 95908 ± 329.43 respectively, this difference was not statistically different (p value = 0.16). neutrophils count was 66. 86% in patients with inflamed appendix and nearly equal to this 65.18% was noticed with normal appendix on histopathology (p value = 0.15) table 2: frequency of acute appendicitis based on postoperative histopathological findings in patients with normal and raised wbc count.(n=100) white blood cell count acute appendicitis on histopathology n (%) normal appendix on histopathology n (%) p value leukocytosis (n=32) 23(71.9) 9(28.1) 0.02* normal tlc (n = 68) 61 (89.7) 7(10.3) neutrophilia (n=35) 30 (85) 5(14.3) 0.73 normal neutrophil count n= 65 54(83.1) 11(16.9) cut off point of for total leukocyte count (tlc): 11,000 wbcs/µl, neutrophil count cut off: 75%, p value < 0.05 considered significant on histopathological findings, seventy four percent of the specimens divulged neutrophil infiltration of the mucosal and muscularis layer extending into the lumen and there was ulceration in mucosa. ten percent the specimens had hyperplasia of lymphoid follicles that suggested early pathological changes. per operative, appendiceal luminal obstruction was seen in 36% of patients. table 3: sensitivity and specificity of wbc for diagnosis of appendicitis. sensitivity 27.38% specificity 43.75% positive predictive value 71.87% negative predictive value 10.1% acute appendicitis on the basis of on histopathology was found in 61 (89.7%) in patients with normal tlc and only 23 (71.9%) in patient with raised tlc, however appendix was found normal in 9(28.1%) of patients even with raised tlc (table 2). table 4:binomial logistic regression analysis: predicting acute appendicitis by wbc count (n=100) white blood cells odd ratio 95% confidence interval p value total leukocyte count 0.297 0.99 -0.89 0.30 neutrophil count 1.23 0.309 4.932 0.76 wbc = white blood cells, p value< 0.05 considered significant sensitivity and specificity of wbc count is presented in table 3. table 4 shows insignificant odd ratios indicating that tlc and neutrophil count was not independent predictors of acute appendicitis. discussion acute appendicitis is still a diagnostic challenge. some of the patients may have atypical symptoms of the disease. though ultrasound and ct scan is being used on a large scale but there is no significant change in reducing the rate of negative appendectomy or misdiagnosis of acute appendicitis and subsequent complication like perforated appendix.12 different inflammatory markers are being assessed that may help in diagnosis of the disease. differential leukocyte count is globally used to diagnose acute appendicitis for many past decades, however now in this recent era many of the researchers has reported conflicting results and found acute appendicitis even with normal wbc count. we conducted the study to know if tlc count wbcs count for appendicitis j aziz fatm med den college july december 2021; vol. 3, no. 2 59 is helpful in finally establishing the diagnosis but we have concluded that we cannot rely wholly on wbc for operative decision. clinical judgment is still on the top of list for the diagnosis and operative decision of acute appendicitis.13 in the current study, contrary to the routine impression that normal tlc rules out the differential diagnosis of acute appendicitis, a substantial proportion of patients found to have acute appendicitis on histopathology report even with the normal wbc count .the results of our study have shown that total leukocyte count is not a diagnostic criteria for acute appendicitis since it was found normal in 89.7% of patients who were having histopathological evidence of acute appendicitis. similarly 28.1% patients with raised tlc had normal appendix on histopathology. our results showed the sensitivity, specificity, positive predictive value and negative predictive value of wbc count was 27%, 43.75%, 71.87% and 10.1% that is contrary to joshi a et al.14 yokoyama et al study favors result of our study that wbc count and neutrophil count are not helpful for surgical indications. 15 recent studies suggest that a significant number of patients of acute appendicitis have normal tlc and neutrophil count. so they should be observed carefully before discharging them.16 previous study of bilal m, et al strongly favors results of our study who found that tlc count was normal in 83.2% of patients.11 our findings are in accordance with study by er s et al also reported that 81% of the patients with a normal wbc count had acute appendicitis while 19% had a normal appendix.17alam et al also concluded normal tlc count in 83.9% of patients with diagnosis of acute appendicitis based upon clinical findings.18 apart from the tlc , we also noticed that the 83.1% patients with normal neutrophil count had inflamed appendix and 14.3% of the patients with raised neutrophil had the normal appendix. contrary to our findings in al-gaithy et al study documented that tlc with predominance of neutrophil counts were significantly higher in patients with inflamed and complicated than normal appendix.19in current study we found insignificant or ratios reflecting wbcs count are not useful for predicting diagnosis of acute appendicitis. our results are supported by er s etal, who also reported insignificant or.17a complete clinical examination of patient is more important than laboratory evaluation of wbc count. normal wbc count does not rule out acute appendicitisin our study, pain in right iliac fossa was present in 100% of patients, anorexia in 92% of patients, nausea and vomiting in 89%, fever in 42% of patients, tenderness in 97% and rebound tenderness in 74% of patients. nepal, rabindra et al established a near similar percentage of rif pain (100.0%), rebound tenderness (82.1%), anorexia (80.2%) and nausea/vomiting (74.5%) in patients with clinical diagnosis of acute appendicitis.20 similarly the generalized pain was also reported in 100% of patients of al-gaithy et al study.19 estimation tlc and neutrophil count is not sufficient for the diagnosis of acute appendicitis, and normal tlc values cannot exclude acute appendicitis. the clinical evaluation of the surgeon should continue to be a priority in diagnosing acute appendicitis to prevent undesirable complications such as perforation and peritonitis represents a very serious dilemma for surgeons. conclusion white blood cell count is not a very good and reliable investigation for diagnosis of acute appendicitis. one must rely upon clinical findings to make final decision for appendectomy. it also does not indicate severity of disease, here again clinical findings are more reliable. also the sensitivity of this test is not sufficient to rule out the disease. conflict of interest: none funding source: none references 1. kabir sa, kabir si, sun r, jafferbhoy s, karim a. how to diagnose an acutely inflamed appendix; a systematic review of the latest evidence. international journal of surgery. 2017; 40:155-162. 2. virmani s, prabhu ps, sundeep pt, kumar v. role of laboratory markers in predicting severity of acute appendicitis. african journal of paediatric surgery: afr j paediatr surg. 2018 ;15(1):1–4. doi: 10.4103/ajps.ajps_47_16 3. mekhail p, naguib n, yanni f, izzidien a. appendicitis in paediatric age group: correlation between preoperative inflammatory markers and postoperative histological diagnosis. afr j paediatr surg. 2011;8(3):309-312.doi: 10.4103/0189-6725.91676 4. bhangu a, s reide k, di saverio s, assarsson jh, drake ft. acute appendicitis: modern understanding of pathogenesis, diagnosis, and management.thelancet.2015;386(10000):12781287.doi:10.1016/s0140-6736(15)00275-5 5. khan ji, nawaz m, sultan n. role of total leukocyte count in diagnosis of acute appendicitis. international journal of health andmedicalsciences.2017;3(2):5053.doi:10.20469/ijhms.3.30004-2 6. sellars h, boorman p. acute appendicitis. surgery (oxford). 2017;35(8):432438.http://dx.doi.org/10.1016/j.mpsur.2017.06.002( cited on: june4-2021) 7. er s, çomçalı b, soykurt a, cavit yüksel b, tez m: diagnosis of appendicitis in patients with a normal whiteblood cell count; a cross-sectional study. bull emerg trauma. 2018; 6:128-132. 8. kamran h, naveed d, nazir a, hameed m, ahmed m, khan u. role of total leukocyte count in diagnosis of acute appendicitisjayub med coll abbottabad. 2008 ;20(3):70-71 9. dnyanmote a, ambre sr, doshi f, ambre s: role of total leukocyte count and c-reactive protein in diagnosis of acute appendicitis. int surg j. 2018; 5(3):883-887. sarwat bibi et al https://www.ncbi.nlm.nih.gov/pmc/articles/pmc6419549/ https://dx.doi.org/10.4103%2fajps.ajps_47_16 http://dx.doi.org/10.1016/j.mpsur.2017.06.002 https://dx.doi.org/10.29252/beat-060207?utm_medium=email&utm_source=transaction https://dx.doi.org/10.29252/beat-060207?utm_medium=email&utm_source=transaction 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morbidity and mortality. 2008;6:9. 14. joshi a, dange a, apturkar d, saxena p. study of values of c reactive protein, total leuckocyte count and neutrophil counts in diagnosis of acute appendicitis. indian j basic appl med res. 2017;7:59-61 15. yokoyama s, takifuji k, hotta t, matsuda k, nasu t, nakamori m et al. c reactive protein is an independent surgical indication marker for appendicitis: a retrospective study. world j emerg surgery. 2009 ;4(1):1-5. 16. singh ca, singh ap, sajith bsm, gaharwar aps: role of alvarado score in diagnosis and management of acute appendicitis. int j sci stud. 2016, 4:173-7. 17. er s, çomçalı b, soykurt a, cavit yüksel b, tez m. diagnosis of appendicitis in patients with a normal white blood cell count; a cross-sectional study. bull emerg trauma. 2018 ;6(2): 128–132.doi: 10.29252/beat-060207 18. alam b, malik z, ibrar m, abdu llah mt, waqar sh, zahid ma: high total leukocyte count in the diagnosis of acute appendicitis. j med sci. 2014; 22:84-88. 19. al-gaithy zk. clinical value of total white blood cells and neutrophil counts in patients with suspected appendicitis:retro spective study world j emerg surg. 2012; 7: 32 . doi :10.11 86/1749-7922-7-32 20. rabindra kc, lohani i: comparison of the use of neutrophil: lymphocyte count ratio (nlcr) to total leukocyte count in diagnosing appendicitis in adults. j soc surg nepal. 2018, 21:24-27. received: 09 apr 20201, revised received: 20 nov 2021, accepted: 21 nov 2021 wbcs count for appendicitis author’s contribution: dr. sarwat bibi concept, literature search, data collection, analysis, first draft writeup. dr. khurram saqib literature search, data collection, results, second draft write up. dr. m. saleem study concept and design, analysis, final review, overall supervision. dr. aalia farhan data collection statistical analysis proved the manuscript. dr. humaira ahmad concept, data analysis & approved the manuscript. dr. hamza rana concept, result write up & approved manuscript. all authors are equally accountable for research work and integrity https://pubmed.ncbi.nlm.nih.gov/30215950/?utm_medium=email&utm_source=transaction https://pubmed.ncbi.nlm.nih.gov/30215950/?utm_medium=email&utm_source=transaction http://www.ijss-sn.com/uploads/2/0/1/5/20153321/ijss_sep_oa36_-_2016.pdf?utm_medium=email&utm_source=transaction http://www.ijss-sn.com/uploads/2/0/1/5/20153321/ijss_sep_oa36_-_2016.pdf?utm_medium=email&utm_source=transaction http://www.ijss-sn.com/uploads/2/0/1/5/20153321/ijss_sep_oa36_-_2016.pdf?utm_medium=email&utm_source=transaction https://www.ncbi.nlm.nih.gov/pmc/articles/pmc5928269/ https://www.ncbi.nlm.nih.gov/pmc/articles/pmc5928269/ https://dx.doi.org/10.29252%2fbeat-060207 https://www.jmedsci.com/index.php/jmedsci/article/view/277?utm_medium=email&utm_source=transaction https://www.jmedsci.com/index.php/jmedsci/article/view/277?utm_medium=email&utm_source=transaction https://www.ncbi.nlm.nih.gov/pmc/articles/pmc3502286/ https://www.ncbi.nlm.nih.gov/pmc/articles/pmc3502286/ https://www.ncbi.nlm.nih.gov/pmc/articles/pmc3502286/ http://nepmed.nhrc.gov.np/index.php/jssn/article/view/451?utm_medium=email&utm_source=transaction http://nepmed.nhrc.gov.np/index.php/jssn/article/view/451?utm_medium=email&utm_source=transaction http://nepmed.nhrc.gov.np/index.php/jssn/article/view/451?utm_medium=email&utm_source=transaction j aziz fatm med den college july december 2020; vol. 2, no. 2 38 original article frequency of eosinophilia among patients of chronic obstructive pulmonary disease with acute exacerbation masood javed, ghulam abbas sheikh, muhammad rizwan, rizwan rasul khan, nasir mehmood, mubarak ali anjum abstract objective: to determine the frequency of eosinophilia among patients of chronic obstructive pulmonar y disease with acute exacerbation methodology: this cross-sectional study was carried out at aziz fatimah hospital (afh), faisalabad from february 2020-may 2020. ethical approval was taken from institutional ethical committee of aziz fatimah medical and dental college. after obtaining informed consent, 135 patients of chronic obstructive pulmonary disease were enrolled by non-probability consecutive sampling technique according to inclusion and exclusion criteria. all the information was collected on predesigned proforma. blood samples were drawn and sent to the afh pathology laboratory for determination of eosinophilia. statistical analysis was performed by spss 21. mean and percentages were determined for continuous and categorical variables respectively. chi square test was applied for differences in proportions. results: this study comprised of 135 patients of chronic obstructive pulmonary disease. out of total participants 48.89% (n=66) were male and 51.11% (n=69) were females. mean±sd of the age of the study subjects was 56.30±7.01 years. eosinophilia was found in 39.26% (n=53) patients of chronic obstructive pulmonary disease with acute exacerbation. conclusion: eosinophilia is frequently found in patients of chronic obstructive pulmonary disease with acute exacerbation. keywords: acute exacerbation chronic obstructive pulmonary disease, eosinophilia. introduction chronic obstructive pulmonary disease (copd) especially with frequent exacerbations increases the ___________________________________________ masood javed, mbbs, fcps professor aziz fatimah m edical college and hosp ital fsd ghulam abbas s heikh, mbbs, fcps professor aziz fatimah m edical college and hosp ital fsd muhammad rizwan, mbbs, fcps assistant p rofessor aziz fatimah m edical college and hosp ital fsd rizwan rasul khan, mbbs, fcps associate professor aziz fatimah m edical college and hosp ital fsd nasir mehmood, mbbs, fcps associate professor aziz fatimah m edical college and hosp ital fsd mubarak ali anjum, mbbs, fcps assistant professor aziz fatimah m edical college and hosp ital fsd correspondence: masood javed email: drmasood1960@gmail.com economic burden up to 50-75% on health care system of any society because of more visits to opd clinic s and also increased number of hospitalizations.1 in copd there is progressive air flow limitation which interferes with normal life activities and is not fully reversible. factors responsible for it may be abnorma l inflammatory response to noxious gases or particles like tobacco smoke, biomass solid fuel, coal, crop residues etc. moreover, in addition to this airway hypersensitivity which may cause exacerbation of the disease sometimes may even requires the change of treatment.2 acute exacerbation of chronic obstructive pulmonary disease (aecopd) means aggravation of symptoms and deterioration of the pulmona ry function tests (pfts) by infection or change in quality of air, resulting in respiratory failure or even death.3,4 copd is considered to be a progressive , debilitating disease resulting in approximately 23% of all the respiratory diseases related moralities, a fact which is especially observed in case of aecopd.3,5 it aggravates the situation by rapid progression of the disease, poor quality of life and higher mortality rate.6apart from a predominant neutrophilic pattern of inflammation, various research studies show that j aziz fatm med den college july december 2020; vol. 2, no. 2 39 eosinophils also play role in the underlying pattern of inflammation in about 1/3 patients of copd. although it is a fact that eosinophilia is commonly associated with bronchial asthma which is indicated by blood and sputum eosinophilia. this phenomenon is also seen in copd patients and more consistently in cases of aecopd.7 it has also been observed that this fact depends upon specific population under study and on eosinophil threshold. presence of eosinophilic inflammation in the copd patients is very significa nt as it predicts response to inhaled corticosteroids (ics) for prevention and systemic corticosteroids (scs) for the treatment of aecopd. detection of eosinophilia from the sputum is more time consuming and samples of sputum may also be inadequate. comparatively determination of blood eosinophil count is easy and practically a surrogate biomarker for sputum eosinophilia, in copd and aecopd.8,9 in this regard pavord et al detected eosinophilia in 74% of patients in tristan study whereas couillard et al observed blood eosinophilia in 32.90% of copd patients.3,10 both aforementione d studies signify the important role of eosinophilic inflammation in the pathophysiology of aecopd, although a lot of variation in eosinophil count is seen in these studies. recent research has elaborated role of eosinophils in prediction and treatment of copd and acute exacerbation of copd. high level of eosinophils in blood is now taken as a possible biomarker in the diagnosis and management of exacerbation of copd.11 due to conflicting results reported by the previous researches, impact of eosinophilia on the prognosis of copd exacerbations is still under debate. some previous studies have documented the high rate of exacerbation with eosinophilia, while others suggested fewer aggravating attacks. numerous studies have reported high blood eosinophils count in copd patients results in longer hospital stay with high risk of mortality.12 regarding pathogenesis, it is suggested that eosinophilia is because of expression of more comple x chemokines including rantes (regulated upon activation normal t-cell expressed and secreted) responsible for recruiting inflammatory cells including eosinophils at the sites of inflammation.13 the aim of current study was to explore frequency of blood eosinophilia in copd patients with acute exacerbations. methodology this cross-sectional study was conducted at aziz fatimah hospital (afh) faisalabad from february 2020 to may 2020. ethical approval was taken from institutional ethical committee of aziz fatimah medical and dental college (iec-42-20). sample size of 135 was calculated by using who sample size calculator with prevalence (p) 2.9%7, confidence level = 95 % and absolute precision required = 8% . this study recruited 135 subjects enrolled with nonprobability consecutive sampling technique. copd subjects of either gender with age between 40-80 years having acute exacerbation presenting to medical out patient department (opd) were enrolled. subjects with asthma, pneumothorax, congestive cardiac failure or malignancy, with the history of major surgery in previous four weeks, patients who were on mechanical ventilation, patients receiving anticoagulation therapy and subjects presenting with azotemia (serum creatinine >1.5 mg/dl) were excluded from this study. informed consent was taken from each participant. all relevant information like, age, gender, duration of disease, and medical history were recorded on predesigned proforma. after aseptic techniques blood samples were drawn and sent to the afh pathology laboratory for determination of blood eosinophil count. eosinophilia cutoff value is taken as ≥ 2% (equiva le nt to about ≥150 cells µl−1).11 statistical analysis was performed by spss 21. me a n and standard deviation was calculated for all quantitative variables like age and duration of copd. frequencies and percentages were calculated for all qualitative variables like gender, copd and eosinophilia. chi-square was applied for differences in proportions. p value ≤ 0.05 were taken as significant. results a total of 135 cases of copd with acute exacerbation fulfilling the selection criteria were enrolled in this study to determine the frequency of blood eosinophilia. mean±sd of the age of study participants was 56.30 ±7.01 years. mean duration of copd was calculated as 2.58±0.78 weeks. table 1: frequency of eosinophilia among patients of chronic obstructive pulmonary disease with acute exacerbation (n=135) eosinop hilia no. of p atients (n) percentages (%) yes 53 39.26 no 82 60.74 total 135 100 eosinophilia cut off value was t aken as ≥2% (equivalent t o about ≥150 cells µl -1 ), p value≤ 0.05 is t aken significant. masood javed et al j aziz fatm med den college july december 2020; vol. 2, no. 2 40 on analyzing overall population current results shows that eosinophilia was found in 39.26% (n=53) of the total patients of chronic obstructive pulmonary disease with acute exacerbation, whereas 60.74% (n=82) did not have this finding (table 1). age distribution of the study participants is shown in the table.2 signific a nt difference was not found concerning frequency of eosinophilia among the various age groups of studied population with p-value 1.69 (table2). of total participants, 48.89 % (n=66) were male and 51.11% (n=69) were female. eosinophilia was found almost equally in both genders, significant difference in percentages of eosinophilia among the gender was not found. (p value 1.09). (table no. 3). table 2: comparison eosinophilia among different age groups (n=135) age (y ears) frequency n (%) eosinop hilia yes n (%) no n (%) 40-60 84(62.22) 33(39.3) 51(60.7) 61-80 51(37.78) 20(39.2) 31(60.7) total 135(100) 53 82 p value 1.69 eosinophilia cut off value was t aken as ≥2% (equivalent t o about ≥150 cells µl −1 ), p value≤ 0.05 is t aken significant. table3: comparison eosinophilia frequency on bases of gender (n=135) gender frequency n (%) eosinop hilia yes n (%) no n (%) m ale 66(48.89) 26(39.39) 40(60.6) female 69(51.11) 27(39.13 42(60.8) total 135(100) 53(39.2) 82(60.7) p value 1.09 eosinophilia cut off value was t aken as ≥2% (equivalent t o about ≥150 cells µl -1 ), cop d = chronic obst ructive pulmonary disease. p value ≤0.05 was significant , p value≤ 0.05 is t aken significant. discussion chronic progressive diseases including copd with frequent exacerbations will always remain the largest economic burden on the health care system globally. 3 eosinophilic inflammation is most often associated with bronchial asthma, but researches done in this field have proved that about one third of patients with copd also have blood and/or sputum eosinophilia , although its detection depends upon eosinoph il threshold used and the patient population under study.7,8several previous studies have proposed levels of eosinophil count as a predictor of response to treatment with inhaled corticosteroid (ics) in patients of copd with acute exacerbations.14,15 on the othe r hand, this emerging role for blood eosinophil count as biomarker in copd patients as a guide for inhale d corticosteroid (ics) therapy has been challenge d recently. previous isolde study documented better effects of ics in acute exacerbatio n with lower blood eosinophilic count when compared in subjects with eosinophilia.16 contrary to this flame study has reported superior effects of long-acting β2-agonist (laba), and long-acting muscarinic antagonist (lama) in preventing copd exacerbations irrespective of eosinophil count.17 on the basis of all these researches conducted in various large scale trials , it is now generally considered that a blood eosinophil count ≥2% (equivalent to about ≥150 cells µl−1) is a useful biomarker for the prediction of frequent exacerbations and their prevention with the use of inhaled steroids.11 due to this fact that there is lot of variation in the literature regarding the presence of eosinophilia in patients with aecopd. furthermore , limited data from pakistan is available at nationa l level in this respect. the goal of this study was early detection of blood eosinophilia in copd patients which helps us to take appropriate measures early for its effective prevention and treatment so that the outcome of patients can be optimized and financia l impact of the disease can be minimized. current results reveal that only 39.26% (n=53) of total patients of copd with acute exacerbation showed eosinophilia. the eosinophilia was found equally in both age groups of the study. another previous study conducted at haripur pakistan also reported simila r results.12 current results were also in accordance to couillard et al where eosinophilia was present in 32.9% patients of copd.10 present results are also justified by eclipse study that found 37.4% of patients with persistent high eosinophilia whereas 49% of patients showed intermittent elevation of eosinophils. 1 8 researches are available showing higher percentages and found eosinophilia in 74.77% of copd patients.3there is a marked variations concerning levels of eosinophils in current study with internationa l studies. high prevalence of eosinophilia was reported by poverd et al as compared with our study and another pakistani study from haripur. disparity between pakistani studies and previous international study by poverd et al is probably due to the variability of demographics and diverse ethnicities as samples being taken from twenty-five different countries over the period of one year. contrary to current results another follow up study of the long duration of eight years by oshagbemi et al showed that 80% of patients of copd had high eosinophil counts (≥340 cells/µl) at 6 months of their follow-up. this study suggests that variations in eosinophilic-c ount seen in patients with copd eosinophilia in cop d j aziz fatm med den college july december 2020; vol. 2, no. 2 41 may be related to variations in disease stability (i.e exacerbations) or pharmacologic therapy i.e, ora l corticosteroid courses.19 inconsistent result to our study have been reported from copenhagen,denmark by jabarkhil et al, reporting eosinophilia only 13.2% of copd patients.20 however this aforementioned study concluded that copd exacerbations in patients with eosinophilia have a better prognosis without the higher risk of subsequent exacerbation and lowers three-year mortality rate as compared to subjects with lower count of eosinophil.20 on comparing the eosinophilia among gender, current results shows eosinophilia was equally found copd patients of both genders. our results were not in line with eclipse cohort study that reported persistent elevated blood eosinophils predominantly in old males.18 nevertheless high levels of eosinophils and eosinophil-assoc iated pro-inflammatory factors in the air-ways and blood of patients with copd are highly suggestive of the fact that eosinophils actively contribute to the inflammatory processes in these patients.21 future researches on a broader scales are required for elucidating the underline mechanism of eosinophilia for better management strategies for preventing copd exacerbations and mortality to reduce the burden of this disease worldwide. limitations: it was a cross sectional study, so the casual inferences were not established. sample size was small so results were not generalized to whole population. conclusion eosinophilia is frequently found in patients of chronic obstructive pulmonary disease with acute exacerbation. though, these results are preliminary and further studies, at national level, are required in this respect to substantiate this fact. funding source: none. conflicts of interest: none. references 1. rit chie ai, wedzicha ja. definit ion, causes, p at hogenesis, and consequences of chronic obst ruct ive p ulmonary disease exacerbat ions..clin chest med. 2020 sep;41(3):421-438. doi: 10.1016/j.ccm.2020.06.007 2. vagelmeier cf, criner gj,mart inez fj, anzent o a, bar nes p j,bourbeau j et al. global. st rat egy for t he diagnosis, management and p revention of chronic obst ruct ive lung disease. 2017 report: gold execut ive summary.respirology.2017; 22(3):575 -601. 3. p avord id, lettis s, locantore n, p ascoe s, jones p w, wedzicha ja, et al. blood eosinophils and inhaled corticosteroids/long act ing β-2 agonist efficacy in copd. thorax.2016; 71 (2):118 -125. 4. yang q, lu t , shu c, feng l, chang h, ji q, et al. eosinophilic biomarkers for det ection of acute exacerbation of chronic obst ructive pulmonary disease wit h or wit hout pulmonary embolism. exp ther med. 2017; 14(4):3198-3206. 5. mort ality and causes of deat h collaborators. global, regional and nat ional life expect ancy, all cause mort ality and cause specific mort ality for 249 causes of death,1980 -2015: a systematic analysis for t he global burden of disease st udy 2015.lancet. 2016;388(10053):1459-1544. 6. hinds dr, di sant ost efano rl, le hv, p ascoe s. ident ification of responders t o inhaled cort icosteroids in a chronic obst ructive pulmonary disease population analysis. bmj open. 2016;6(6):14591544. e010099. doi: 10.1136/bmjopen-2015-010099. 7. t ashkin dp , weschsler me. role of eosinophils in airway inflammation of chronic obst ruct ive pulmonary disease. int j chronp ulmon dis.2018; 335-349. 8. kolsum u, donaldson gc, singh r, barker bl, gupt a v, george l, et al. blood and sput um eosinphils in cop d; rerlat ionship with bact erial load. respir res. 2017; 18(1)88. 9. nagewo na, mcdonald vm, baines kj, wark pa, simpson jl, jones p w, et al. peripheral blood eosinophils: a surrogate marker for airway eosinophilia in st able copd. int j chron obstruct p ulmon dis. 2016; 11:1495-1504. 10. couillard s, larivée p , courteau j, vanasse a. eosinophils in copd exacerbat ions are associated wit h increased readmissions. chest.2017; 151(2):366-373. 11. oliver b, t onga k, darley d, rut ting s, zhang x, chen h.et al. copd t reat ment choices based on blood eosinophils: are we t here yet? breat he (sheff). 2019 ;15(4):318-323. doi: 10.1183/ 20734735. 02542019 12. mahmood n, khana, nazir a, yasin m, javed ma, ahmad s. blood eosinophilia in acut e chronic obst ruct ive pulmonary disease exacerbat ion patients. p jmhs. 2020; 14( 3):1178-1180 13. ziot nik a, yoshie o. chemokines: a new classification system and t heir role in immunity. immunity.2000;12(2):121-122 14. sivapalan p p , lapperre t s, janner j, et al. eosinophil guided cort icosteroid t herapy in pat ients admit ted t o hospital wit h copd exacerbat ion (cort ico-cop): a mult icentre, randomised, cont rolled, open-label, non-inferiority trial. lancet respir med. 2019. august ;7(8):699–709 15. harries t h, rowland v, corrigan cj, marshall lj, mcdonnell l, vibhore p rasad v, et al. blood eosinophil count, a marker of inhaled cort icosteroid effect iveness in preventing cop d exacerbations in post -hoc rct and observational st udies: syst ematic review and metaanalysis. respir res. 2020; 21: 3. doi: 10.1186/s12931-019-1268-7 16. wedzicha ja, banerji d, chapman kr, vest bo j, roche n, ayers rt et al indacat erol-glycopyrronium versus salmet erol-fluticasone for cop d. flame invest igators. n engl j med. 2016 ;374(23):2222 2234. doi: 10.1056/nejmoa151638 17. roche n, chapman kr, vogelmeier cf, herth fjf, thach c, fogel r, et al. blood eosinophils and response t o maintenance chronic obst ruct ive pulmonary disease t reatment. data from t he flame trial. am j respir crit care med. 2017;195(9):1189-1197. doi: 10.1164/rccm.201701-0193oc 18. singh d, kolsum u, brightling ce, locantore n, agust i a, tal-singer r. eosinophilic inflammation in cop d: prevalence and clinical charact eristics. eur respir j. 2014;44(6):1697–1700. masood javed et al https://pubmed.ncbi.nlm.nih.gov/32800196/ https://pubmed.ncbi.nlm.nih.gov/32800196/ https://pubmed.ncbi.nlm.nih.gov/32800196/ https://pjmhsonline.com/2020/july-sep/1178.pdf https://pjmhsonline.com/2020/july-sep/1178.pdf https://pjmhsonline.com/2020/july-sep/1178.pdf https://pubmed.ncbi.nlm.nih.gov/27181606/ https://pubmed.ncbi.nlm.nih.gov/27181606/ https://pubmed.ncbi.nlm.nih.gov/27181606/ https://pubmed.ncbi.nlm.nih.gov/28278391/ https://pubmed.ncbi.nlm.nih.gov/28278391/ j aziz fatm med den college july december 2020; vol. 2, no. 2 42 19. oshagbemi oa, burden am, braeken dcw, et al. st abilit y of blood eosinophils in patients wit h chronic obst ructive pulmonary disease and in cont rol subject s, and t he impact of sex, age, smoking, and baseline count s. am j respircrit care med 2017; 195(10):1402–1404. 21. mart inez ch, li sx, hirzel aj, et al. alveolar eosinophilia in current smokers wit h chronic obstructive pulmonary disease in t he sp iromics cohort. j allergy clinimmunol.2017;141(1): 429-43 20. jabarkhil a, moberg m, janner j, p etersen mn, jensen cb, henrik äangquist l, et al. elevated blood eosinophils in acut e copd exa cerbat ions: better shortand long-term prognosis. eur clin respir j .2020;7(1):1757274. doi:10.1080/20018525.2020. 1757274. authors’ contribution: dr. mas ood javed contributed to study design, acquisition of data and manuscript write up. reviewed and approved the manuscript. dr. ghulam abbas she ikh data acquisition, manuscript writing, reviewed and approved the manuscript. dr. muhammad rizwan data analysis and interpretation of results, revising manuscript critically for important intellectual content. dr. rizwan ras ul khan data collection, data analysis and interpretation and write up of results. reviewed and approved the manuscript. dr. nas ir me hmood data collection, revised manuscript critically for important intellectual content and approved it. dr. mubarak ali anjum data collection, drafting and formatting of final manuscript. revised and approve the final manuscript. all authors are responsible for the integrity of the data and the accuracy of the data analysis. received: 15 aug 2020, revised received: 11 sep 2020, accepted: 20 sep 2020 eosinophilia in cop d j aziz fatm med den college july – dec 2021; vol. 3, no. 2 30 original article assessment of anxiety and depression and its association with socio-demographic characteristics among family caretakers of cancer patients khalid hussain, tanseer ahmed, amjad ali, faheem raza abstract objective: to find out the frequency of anxiety and depression and its association with socio-demographics characteristics among family caretakers of cancer patients. methodology: this descriptive cross sectional study of 300 participants was carried out at dr. ruth k.m pfau civil hospital and dow university hospital, karachi from december 01, 2020 to january 30, 2021. before the study ethical approval was taken. the aga khan university anxiety and depression scale (aku-ads) was used to assess the symptoms among family caregivers of cancer patients. the inclined adult male and female family members of cancer patients who were admitted in dow university hospital and dr. ruth k.m. pfau civil hospital karachi was included in this study. the data was analyzed by using spss version -21. frequency analy sis was performed for demographic variables and chi-square test was also run to check the association of anxiety and depression with socio-demographic characteristics of study participants. results: finding of this study revealed that 39% of participants were having anxiety and depression. we found that gender, marital status, age group, educational level and patient’s relationship showed significant p value of <0.001 with anxiety and depression. conclusion: this study concludes that approximately one third of the study participants suffered from anxiety and depression. the demographic variables contributing to anxiety and depression include age, gender, and marital status, relationship with patient and educational level of the participants. keywords: anxiety, association, cancer, chemotherapy, depression. introduction the cancer is the leading source of deaths and this mortality is increasing rapidly day by day.1 as stated by world health organization that 91 countries all over the world evidenced that tumor is the foremost reason of mortality.1 across the globe, 1 in 6 deaths are because of cancer, which indicates its fatalness.2 it is very stressful to provide care to a cancer patient as a family member. being a family caregiver, feelings of pain of loved ones is extremely hurting. among family care providers, both genders have elevated levels of anxiety but females have expressively exce ____________________________________________________________ khalid hussain, m.sc, msn lecturer, jinnah college of nursing, sohail university, khi tanseer ahmed, msn assistant professor dow institute of nursing & midwifery, dow university of health sciences, khi amjad ali, msn, mba assistant professor dow institute of nursing & midwifery, dow university of health sciences, khi faheem raza, msn staff nurse sindh institute of skin diseases, khi correspondence: khalid hussain email: khalid_hamza1982@yahoo.com ssive levels of depression which also affects their quality of life.3 it is also manifested that cancer not only hurts parents or spouses of patients but it could affect the children also. the patient’s kids were on greater risk for psychological, emotional and behavioral concerns.4 earlier studies have shown high incidence of depression and anxiety among family caregivers of cancer clients. a former study revealed that prevalence of depression is found 53% in caregivers. among them, 35% had mild, 16% had moderate and severe depression found in 2% participants.5 in a research study, it is reported that depression is prevalent among cancer caregivers. they noticed 46.56% anxiety level among the same study participants.6 a study had discussed that caregiving of tumor patient have negatively affected the lives of 48% participants in means of social, physical, psychological, professional aspects.7 the parallel degree of depression and anxiety symptoms found in patients with cancer as well as their family members. several factors were documented which have an influence on anxiety and depression. the factors were age, gender, relationship with patient, time spent with the client, duration of disease, marital status, informed consent, financial status, cancer types and stages. j aziz fatm med den college july – dec 2021; vol. 3, no. 2 31 these factors with disease process compromised the quality of life of patients and their loved ones.8 in the local context, it is observed that frequency of depressive and anxiety symptoms have been the part of the studies but some studies have focused on liquid tumors and some solid tumors, few studies paid attention to the patient's parents and some wrote about advanced stages. however, the family members of patients with cancer eventually from commencement of the patient’s life limiting sickness through to terminal illness felt pain which has psychological, occupational and financial impact on them and their care. therefore, our objective to conduct this study was to identify the frequency of depressive and anxiety symptoms among all family caregivers of patients with cancer of all types and stages with all possible treatment methods. methodology the descriptive cross sectional study design was used for this study. purposive sampling technique was preferred. study was conducted during 1st december 2020 to 30th january, 2021. study population consisted of family members of admitted cancer patients in the hematology department of dow university hospital and department of oncology of dr. ruth k.m. pfau civil hospital karachi. for this study, approval was obtained from irc (dionamduhs). permission was taken from medical superintendents of dow university hospital and dr. ruth k.m pfau civil hospital karachi. written informed consent forms were signed by each participant. the inclined adult male and female family members of cancer patients who also had the primary responsibility of financial or economical support for admitted patients were included. all those caregivers who were known cases of depression or anxiety were excluded from this study. the estimation for sample size was made through open-epi online software and the calculated size was 296 by using 26% as prevalence of depression among family members of cancer patients, 5% margin of error, and 95% confidence interval but we took 300 round figure participants. demographic information was taken from the participants and they were asked to fill the aku-ads (aga khan university anxiety and depression scale) questionnaire. aku-ads have 25 items which include 13 somatic and 12 psychiatric symptoms. each question of aku-ads is answered by keeping in mind a time frame of at least 2 weeks. the participants' responses are kept on likert scale like never 0, sometimes 1, mostly 2, or always 3. the participants who took 19 score or above were considered positive for symptoms and those who got scores below 17 and 18 were further interviewed. furthermore, the study participants with a score of 16 or below are considered as neither having anxious nor depressive symptoms. 10 statistical analysis: the spss version-21 was used for data entry and processing. we have run simple descriptive statistics on demographic variables to determine the frequency of anxiety and depressive symptoms. chi-square had also run to check the association between the variables. results total participants were 300, out of them 196 (65.3%) were male and 231 (77%) were married. the study participants were categorized into three age groups. most subjects were in the age group between 20 to 40 years while only 10.3% were old agers. table 1: : demographic characteristics of the study participants (n=300) variables category frequency percentage gender male 196 65.3 % female 104 34.7 % marital status married 231 77.0 % un married 69 23.0 % age group 20 to 40 years 166 55.3 % 41 to 60 years 103 34.3 % 61 to 80 years 31 10.3 % educational level illiterate 105 35.0 % till matric 104 34.7 % above matric 91 10.3 % relationship with patient spouse 66 22.0 % siblings 81 27.0 % parents / children 153 51.0 % cancer stage stage 1,2 20 6.7 % stage 3,4 280 93.3 % treatment type of cancer chemo/radiotherapy 180 60.0 % surgery / palliative 120 40.0 % thirty five % participants were uneducated. fifty one % caretakers belonged to the parent/children category and mostly individuals (51%) belonging to the parents/children category, 93.3% participants were providing care to terminally ill patients. (table 1)this study found a significant association of multiple demographic characteristics with anxiety and anxiety and depression in caregiver of cancer patients j aziz fatm med den college july – dec 2021; vol. 3, no. 2 32 depression. in this regard we found that gender, marital status, age group, educational level and patients relationship showed significant p-value of <0.001 with anxiety and depression, <0.001. while, stages of cancer and treatment types of their patients were not significantly associated table 2: the anxiety & depression association with demographic variables (n=300) variables anxiety & depression association with demographic variables normal anxiety & depression p. value gender male 134 68.36% 62 31.63% <0.001* female 49 47.11% 55 52.88% marital status married 127 54.97% 104 45.02% <0.000* un-married 56 81.15% 13 18.84% age group 20 to 40 years 117 70.48% 49 29.51% <0.000* 41 to 60 years 58 56.31% 45 43.68% 61 to 80 years 08 25.80% 23 74.19% education level illiterate 46 43.80% 59 56.19% <0.000* till matric 71 68.26% 33 31.73% above matric 66 72.52% 25 27.47% relationship with patient spouse 38 57.57% 28 42.42% <0.000* siblings 66 81.48% 15 18.51% parents / children 79 51.63% 74 48.36% stage of cancer stage 1,2 16 80% 04 20% 0.055 stage 3,4 167 59.64% 113 40.35% treatment type chemo / radiotherapy 114 63.33% 66 36.66% 0.186 surgery / palliative 69 57.50% 51 42.50% * p value < 0.05 is considered as significant. with anxiety and depression level with p-value 0.055 table3 : demographic characteristics of the study participants (n=300) n mean sd normal 183(61%) 13.06 3.81 anxiety 117(39%) 23.19 4.49 aku-ads =aga khan university anxiety and depression scale and 0.186 respectively. thirty nine % (117) participants had score >19 on aku-ads showing depression and anxiety in these participants. the mean score of non anxious participants was 13.06 ± 3.81 and for anxious participants was 23.19 ±4.49 (table 3) discussion the main purpose of the study was to observe the frequency of anxiety and depression symptoms among the family caregivers of cancer patients and their association with demographic variables. this study indicates alarming increasing in psychological morbidity in family caregivers of cancer patient. ,n this context female gender, marriage, illiteracy and old age had reported a higher frequency of anxiety and depression. in this study, symptoms like anxiousness, loneliness, insomnia, sensation of impending doom, unhappiness, worries, lack of interest and crying were found more frequently among the female participants as compared to males (52.88 versus 31.62%), reflecting that women are more concerned for their families. this is in affirmation with findings of quiping li et al and katende g et al 8,9while in contrast with kim et al and rumpold et al.3,11 this study showed that nearly about half of the married participants had anxiety and depression, contrary to this, the percentage of anxious and depressive single participants is less than quarter participants. our findings are supported by the previous studies documenting that married people have a higher risk for psychological morbidities.4,12 in current study anxiety and depression were more frequent among the old age group rather than the youngest participants (74.3%versus29.51%). this finding is in line with numerous previous studies.3,10,12 in contrast to our findings padmaja g, et al observed more frequent symptoms of anxiety as well as depression among younger participants.13 some authors were unsuccessful to discover any significant association of age with anxiety and depression.6,11,14 in current study, we found a significant relationship between education level and anxiety and depression. half of the illiterate care takers have symptoms, as compared to more than a quarter of individuals who acquired education till matric. this is, in contrast, to the study of sahedevan et al which found that a higher level of education made individuals more anxious.5 a past study discussed that education is not significantly associated with anxiety and depression symptoms.6 the huge number of illiterate persons having the symptoms of anxiety and depression is strengthening the need for education15,16,17 while certain researchers also point out that matriculate study participants have a higher incidence.9,18 comparing the relationship of the caregiver of a cancer patient, our results were indicated that nearly half of the parent/children have anxiety and depression as compared to less than half of the spouses and less than a quarter of the siblings. khalid hussain et al j aziz fatm med den college july – dec 2021; vol. 3, no. 2 33 our results are justified by shah bk et al that reported a high risk of depressive and anxiety symptoms among kids of cancer patients.4 undoubtedly, these outcomes validate the effects of bounding in relations as revealed in other studies.19,20 the severity of the tumor was discovered as the exaggerating factor among the family members. in current study less than half of the family caregivers of tumor patients with stage iii and iv had symptoms of depression and anxiety. unequally, less than a quarter of study subjects who were the caretakers of stage i, ii patients have the matching signs. similar to current results, previous study by areia et al revealed an alarming prevalence of psychological morbidity in family caregivers of individuals living with terminal cancer.20 inconsistence to our findings, a former study stated that relatives of early stages of cancer had more unhealthy psychological outcomes.21 unanticipated result was noticed by a prior study which revealed that the advanced cancer stage is not associated with symptoms of anxiety and depression.10 the duration of supportive treatment is also upsetting for patients and their caregivers.6 a former research revealed that only chemotherapy augmented the symptoms. alternatively the option of surgery can minimize the psychological symptoms and morbidity.22 the inconsistent outcomes were also scripted.17 two studies exposed the psychological injurious effects of chemo and radio therapy upon the family caregivers.8,23 the cancer caregivers of patients with palliative treatment may also perceive the physical decline and death.14,24 regardless of the above quoted findings, no association was found between the treatment type and anxiety and depressive symptoms.21 healthcare experts need to pay more consideration to the psychological aspects of families and make sure the provision of counseling and support as part of their whole management. nurses can also play a key role in counseling and motivation of cancer patients and their loved ones for reducing the anxiety and depression in this vulnerable group. given the alarming risk of psychological morbidity for family caregivers of people living with cancer patients, it is hoped that this work will intricate future research in the field and raise awareness of the importance of better support for families that face the imminent death of a family member. limitations: as this was a cross-sectional study, so any unintentional relationships cannot be gathered. secondly, our variables like stage of disease and treatment type did not touch significance. furthermore, the symptoms of anxiety and depression were assessed by aku-ads and they could be analyzed with other tools. hence, this analysis did not explore the time duration, hospital stay, financial support, screening method of diagnosis of the cancer. moreover, well-designed and multi-center studies involving private hospitals taken into account are boosted in future. conclusion the frequency of symptoms of anxiety and depression among family caregivers of tumor patients were found elevated, specifically among females and older individuals. the demographic variables such as age, gender, marital status, relationship with patient and educational level were recognized as predictors of anxiety and depressive symptoms. the type of the cancer treatment and stage of disease did not have considerable influence on caregiving. conflict of interest: none. source of funding: none references 1. bray f, ferlay j, soerjomataram i, siegel rl, torre la, jemal a. global cancer statistics 2018: globocan estimates of incidence and mortality worldwide for 36 cancers in 185 countries. ca cancer j clin,2018. 68(6), 394424. doi:https://doi.org /10.3322/ caac.21492 2. who, cancer fact sheet: who; 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17(3) : 286-293. https://doi.org/10.1017/s1478951518000044 21. toledano-toledano f, de la rubia jm. factors associated with anxiety in family caregivers of children with chronic diseases. biopsychosocmed.2018;12(1):110.https://doi.org/10.1186/s13030 -018-0139-7 22. govina o, vlachou e, kalemikerakis i, papageorgiou d, kavga a, konstantnidis t. factors associated with anxiety and depression among family caregivers of patients undergoing palliative radiotherapy. asia pa j oncol nurs. 2019;6(3):283291. doi: https://doi:10.4103/apjon.apjon_74_18 23. alemayehu m, deyessa n, medihin g, fekadu a. a descriptive analysis f depression and pain complaints among patients with cancer in a low income country. plos one. 2018;13(3):e0193713.https://doi.org/10.1371.journal.pone.0193713 24. johansen s, cvancarova m, ruland c. the effect of cancer patients’ and their family caregivers’ physical and emotional symptoms on caregiver burden. cancer nurs. 2018 mar 1;41 (2) : 9 199.doihttps://doi:10.1097/ncc.0000000000000493 author’s contribution: khalid hussain study design, literature search and review, data collection, manuscript writing, tanseer ahmed design of study, data analysis and interpretation, critically revise the manuscript for all intellectual content and make all necessary revision in manuscript. check and correct all the references carefully and approved the article amjad ali faheem raza data analysis and interpretation of results, critically revise the manuscript for all intellectual. conception and design of the study, drafting, review, revision and literature search, data collection and compilation. received: 06 sep 2021, revised received: 11 oct 2021, accepted: 21 oct 2021 khalid hussain et al https://doi.org/10.1080/07481187.2019.1614108 https://doi.org/10.1080/07481187.2019.1614108 https://dx.doi.org/10.7759%2fcureus.1397 https://doi.org/10.27619%20/emhj.19.005 https://doi.org/10.27619%20/emhj.19.005 https://dx.doi.org/10.22034%2fapjcp.2017.18.2.465 https://dx.doi.org/10.22034%2fapjcp.2017.18.2.465 https://doi.org/10.1186/s13030-018-0139-7 https://doi.org/10.1186/s13030-018-0139-7 https://dx.doi.org/10.4103%2fapjon.apjon_74_18 https://doi.org/10.1371.journal.pone j aziz fatm med den college july december 2021; vol. 3, no. 2 40 original article knowledge & practices of breastfeeding in working and non-working mothers muhammad hashir iqbal, namra noukhaiz, saadia shahzad abstract objective: to assess knowledge and practices of mothers towards breastfeeding and identify the association of socio demographic factors with knowledge and breastfeeding practices among mothers. methodology: a descriptive cross-sectional study conducted in outdoor departments of pediatrics & gynecology in a tertiary level hospital in lahore. the study population was mothers having children ≤5 years of age. study variables included socio-demographic factors, knowledge & practice factors. the calculated sample size was 362 and a purposive sampling technique was applied. the data collection instrument was a self-developed questionnaire. the data analysis plan was: descriptive statistics, frequency trends, and chi-square test of significance application. results: demographic profile showed 75.5% of mothers were housewives and 24.3% working mothers; 42% were living in a nuclear family, 58% in an extended family. knowledge level revealed that 36.5% knew breastfeeding (bf) should be done up to 2 years; 75.5% knew that it should be given on demand; 91% knew that colostrum should be given to the newborn. practice level assessment showed 44.5% had initiated bf immediately after birth; 79.9% had given colostrum; and 34.9% had done bf > one year. significant association <0.05 was found between socio-demographic factors (status of mother, type of family, total family income, mode of delivery) and knowledge and practice variables. conclusion: there is an important role of an extended family system that could act as a support pillar to enhance the practice of breastfeeding practices among mothers. furthermore, at home mothers and lower socio economic class also play an important role as contributing factors in continuation of bf >6 months. keywords: breastfeeding, initiation, knowledge, newborn, practice. introduction breastfeeding behaviors are mostly dependent upon the specific cultural norms and perceptions of the mothers that actually guide them towards duration and frequency of breastfeeding to the infant. 1 breast milk prevents malnutrition in the newborn and boosts up its immunity.3timely and early initiation of breastfeeding by the mothers play an important role in control of infections and mortality in infants.4 the world health organization (who) and united nations children’s fund (unicef) have strongly recommended all nursing mothers to initiate breastfeeding within first muhammad hashir iqbal mbbs student shalamar medical and dental college, lhr namra noukhaiz mbbs student shalamar medical and dental college, lhr dr.saadia shahzad, mbbs, mphil associates professor shalamar medical and dental college, lhr correspondence: dr. saadia shahzad email: saadia.shahzad@sihs.org.pk hour after birth of the newborn and then continue with exclusive breastfeeding for next six months; specifically, in low economic and developing countries.5the who also advocates that breastfeeding is to be continued along with complementary feeding up to the age of two years or beyond.5 however, many unhealthy breastfeeding practices are seen in developing countries like pakistan; where infant and child mortality rates are high and infection rate among infants is high.6 various researchers have identified multiple influencing factors that affect the early initiation and duration of breastfeeding among mothers; like their age, education level, income, marital status, and professional career, information from media and literature, and family support.7 it so happens that with an increase in the age of the child, practices of breastfeeding by the mothers’ decline. the first two hours after birth is labeled as the sensitive period and is the optimum time to start breastfeeding to the child, and unfortunately, only 29% of the newborn get breastfeed during this time.9 with this scenario in mind, the current study was planned to assess breastfeeding knowledge and practices among working and non-working mothers in mailto:saadia.shahzad@sihs.org.pk j aziz fatm med den college july december 2021; vol. 3, no. 2 41 a lower socio-economic community. current study results will also guide us towards the planning of an effective exclusive breast feeding (ebf) promotion drive in the said locality to improve the situation further and to raise awareness among the community about the significance of ebf and its impact upon the health of child and mother both. we aimed to assess the knowledge and practice level of mothers towards breastfeeding and identify the association of socio demographic factors with knowledge and breastfeeding practices among mothers. methodology it was a descriptive cross-sectional study conducted in the outdoor departments of pediatrics and gynecology in a tertiary level hospital situated in a lower socio-economic category area of lahore during june 2018 to dec 2018. irb approval was taken from the organization (letter no: smdc/ irb/ 01-03/083) study universe was married females of reproductive age group visiting the selected hospital outdoor departments for health care. the study population was mothers having children ≤5 years of age. study variables included: socio-demographic variables and variables for knowledge and practice regarding breastfeeding, in their last, birth. inclusion criteria were: willingness of the respondent and mothers having children ≤5 years of age. whereas exclusion criteria were: mothers having children above the listed age and mothers who had participated in research of a similar kind. the sample size was calculated upon open epi software using the prevalence of exclusive breastfeeding of 38%, ci of 95%, and 5% margin of error.9 the calculated sample size was 362. purposive sampling technique was applied to select our study sample and respondents were recruited for the study after due written informed consent. data collection tool was the interview method and the data collection instrument was self-developed questionnaire related to breastfeeding, in the last born child. questions included in the questionnaire were selected after a detailed reading of the relevant material upon breastfeeding by the world health organization (who). data was collected by the female team members on account of the sensitive nature of the questions and cultural limitations. statistical analysis: the data analysis plan was developed as a descriptive statistics calculation, frequency trends in knowledge and practice sections, and chi-square test of significance was applied. results total data of 362 respondents was collected. we obtained hundred percent response rate which was entered on spss 20 and analyzed. the mean age of mothers was 28 years±4.95 with a range of 16-42 years. we found that 356(98.3%) of mothers had ≤3 children and only 6(1.7%) mothers had > three children. table 1: knowledge level of mothers regarding breastfeeding in their last born (n=362) variable response n (%) should mother’s milk be given to child immediately after birth yes no 328 (90.6%) 34 (9.4%) should colostrum be given to the child yes no 325 (91.1%) 36 (9.9%) for how long breastfeed should be given up to 4 months up to 6 months up to 1 year up to 2 years 38 (10.5%) 103 (28.45%) 89 (24.58%) 132 (36.46%) how many times should mother’s milk be given to the child in a day 1-4 times 5-8 times on-demand 28 (7.7%) 60 (16.6%) 274 (75.7%) when should you start solid food for a child at 4 months at 6 months 8 months-1 year 85 (23.5%) 255 (70.4%) 22 (6.1%) after weaning should mother’s milk be given to a child yes no 348 (96.1%) 14 (3.9%) should mother’s milk be given to child during illness yes no 331 (91.4%) 31 (8.6%) does mother’s milk strengthens immunity in a child yes no 355 (98.1%) 7 (1.9%) does breastfeeding reduces the risk of breast cancer in mother yes no 255 (70.4%) 107(29.6%) do you know the benefits of breastfeeding yes no 314 (86.7%) 48 (13.3%) results showed that 274(75.7%) mothers were housewives and 88(24.3%) were working mothers (majorities are teachers, few had their own small business, and only one or two are doctors). the present study found that 152(42%) mothers were living in nuclear family type and 210(58%) in extended family type. according to the results, 198(54.7%) mothers had their last born through cesserian section and 164(45.3%) through normal vaginal delivery (nvd). kap study breastfeeding j aziz fatm med den college july december 2021; vol. 3, no. 2 42 table 2: practice level in mothers regarding breastfeeding in their last born (n=362) variable response n (%) what did you give your last born child immediately after birth pre lacteals colostrum water top feed 141 (39%) 181 (50%) 6 (1.6%) 34 (9.4%) when did you give breastfeed after birth immediately after one day after two days 141 (44.5%) 136 (37.6%) 65 (18%) did you give colostrum to your child yes no 289 (79.9%) 72 (19.1%) for how long did you breastfeed your baby did not breastfeed 28 (7.7%) <4 months 4-6 months 6-12 months >12 months 6 (1.6%) 37 (10.2%) 165 (45.5%) 126 (34.9%) how many times do you breastfeed your child in a day 1-4 times 5-8 times on-demand 30 (8.3%) 63 (17.4%) 268 (73.5%) in case of a child’s upset stomach do you continue to breastfeed yes no 325 (89.8%) 37 (10.2%) did you choose to breastfeed to reduce the risk of breast cancer yes no 206 (56.9%) 156 (43.1%) did you practice breastfeeding after weaning yes no 322 (89%) 40 (11%) did you give top feed to last born yes no 252 (69.6%) 110 (30.4%) p-value ≤0.05 is significant table 3: associations of demographic variables and knowledge of initiation of breastfeeding soon after birth variable should mother’s milk be given to baby instantly after birth chisquare value pvalue status of mother housewife working yes no 5.984 .020* 254 20 73 14 type of family nuclear extended yes no 5.249 .028* 144 8 184 26 total family income <25000 25000-50000 50001-85000 >85000 yes no 11.197 .011** 114 8 119 21 48 5 47 0 p-value <0.05 is significant educational level of mothers showed: 36% mothers had education up to matric, forty five percent had intermediate-graduate level, and nineteen percent had postgraduate level education. in our study it is found that the total family income of the respondents revealed: thirty four percent had <25000/ month, fifty three percent had 25001-85000/ month, and only thirteen percent had >85000/ month. table 4: association between variables and duration of breast-feeding practices ≤6 &>6 months variable duration of breastfeeding chi square value p-value status of mother ≤6 months >6 months 4.052 0.045* house wife 115 159 working 26 61 mode of delivery ≤6 months >6 months 5.713 0.022* c-section 64 128 nvd 75 89 type of family ≤6 months >6 months 6.636 0.012** nuclear 71 81 extended 70 140 total family income ≤6 months >6 months 10.712 0.013** <25000 55 67 25000-50000 60 80 50001-85000 16 37 >85000 10 37 nvd= normal vaginal delivery, p-value ≤ 0.05 is significant discussion as per who recommendation, initiation of breastfeeding to the infant should be within the first sixty minutes’ after birth. the initial start with colostrum is a rich source of antibodies and nutrients. present study patterns of socio-demographic characteristics are supported by the findings of pakistan demographic and health survey (pdhs) 2017-18 which states: 49% of women had no education, 17% had primary level, 9% had middle level, 12% had secondary level, and 13% had education up-till higher level. this survey also found that the general current employment rate in women is 17%. specific current employment rate for various age groups was 96% among women of age 15-44 years; with more involvement of urban women in professional/ technical/ managerial jobs 25% and 43% in skilled manual work. furthermore, the survey reported that 58.3% women were from the lowestmiddle wealth quintile and only 41.9% from fourthhighest quintile. survey reported that 15.3% women had 1-2 children and 15.1% had 3-4 children.10 another study conducted in pakistan found that only 10% of the respondent women were employed in regular jobs; the pattern of educational level of mothers; and household monthly income trends in this study are also similar to our study findings.11 demographic profile in our study is also consistent with another study conducted in a rural area in india, saadia shahzad et al j aziz fatm med den college july december 2021; vol. 3, no. 2 43 upon 250 respondents from different religious backgrounds.12 in our study the knowledge level of women regarding breastfeeding is highly satisfactory upon all the key aspects. the good knowledge level of the respondents regarding all the important aspects of bf is the strength of our study and findings are consistent with another study conducted in pakistan that found: 89% mothers knew about the importance of bf, 42% of mothers did not add any substitute for breast milk. 11 still our findings upon the knowledge level of women regarding some aspects of bf are much higher than this past study that found: 36% women did not have any idea about early initiation of bf to the newborn, and 44% had no idea about the importance of giving colostrum to the newborn.11 in another study conducted in a rural area in india kap of mothers (belonging to diverse religions) was assessed regarding bf, and authors of this study found similar trends of knowledge level of mothers regarding importance of bf, initiation of bf, giving colostrum to the newborn, and about importance/ otherwise of prelecteals.12 our findings are also supported by another study conducted in pakistan that showed similar trends of knowledge level in mothers regarding the different significant aspects of breastfeeding. 13 present study findings upon knowledge level regarding breastfeeding among women are strongly supported and are similar to the findings of few other comparative studies that show the same pattern as; 66% mothers in india and 99% mothers in sri lanka responded that breastfeeding strengthens the immunity of the child.14,15 the findings of our respondents upon knowledge level are also consistent with the jordanian study that found a similar pattern among the study subjects stating that majority of mothers answered correctly about the nutritional benefits of breast milk, a little more than half of the mothers knew whether breastfeeding should be stopped or not when baby is sick, and majority knew that breastfeeding protects against breast and ovarian cancers.16 our study also found that mothers were in the practice of giving pre-lacteals to the last born; that included pure honey. this finding is similar and supported by another study conducted in india that had a similar finding.14 practice level regarding bf among our study participants has shown remarkable results in all the important areas: majority mothers knew that colostrum had to be given to the newborn immediately after birth and they had done so in their last born; near about half of the respondents had initiated bf soon after birth which is far less than a previous study that found higher rate (72.4%) of early initiation of breastfeeding soon after birth,16 and then some had done so after one day some after two days; majority had breastfed their last born for 4-12 months and >12 months; majority had done ondemand breastfeeding, had continued breastfeeding after weaning; majority knew that breastfeeding prevents from breast cancer, and majority practiced continuation of breastfeeding during an episode of illness of the child. these findings are supported by the national level survey of pakistan that found: almost all last born children less than two year of age were breastfed, with 20% of the children breastfed in the first hour after birth and 56% are breastfed within a day of birth. 10 our findings are also similar to a past indian study that investigated the knowledge, attitude, and practices of mothers regarding breastfeeding.12 these findings are also consistent with the findings of breastfeeding practices investigated in a study conducted in lahore, pakistan that reported similar trends of breastfeeding practices as in our study.13 in the present study breastfeeding practice rate in 4-6 months’ infants is again lower than some past studies that found breastfeeding rate for four months’ duration as: 20.9% 16; 31% 14; and 49%.15 results also showed a highly significant association of family income with knowledge of immediate onset of breastfeeding after birth; with a greater proportion of mothers in the category of <25000 and up to 50000 per month. a significant association was found with the status of mothers with a large number in the category of housewives as compared to working mothers. we also had significant association with the type of family with the majority of mothers in the category of the extended family system. logically these findings can be explained by the fact that most of the families in this socio-economic group are living in an extended family system in our culture. hence, there is the possibility of the impact of lower socioeconomic status, greater social pressure on the mother as well as the age-old inherited knowledge of the elders regarding early initiation of breastfeeding can also play a role in it. recent national level survey in pakistan found that median duration for any breastfeeding decreases with household wealth, from 22.3 months in the lowest quartile to 12.3 months in the highest quartile.10 this same survey found that children of illiterate mothers had a median duration of 21 months as compared to 12.3 months among the children with highly educated mothers.10 though, in our study we could not find significant association of mother’s education level with breastfeeding. present study found a significant association of demographic factors: status of mother (working/ housewife), type of kap study breastfeeding family (nuclear/ extended), total family income, and type of delivery (normal/ c-section); with duration of breastfeeding practices. in all these significant associations a greater proportion of mothers was found in the group of housewives, from households with lower household income groups, and mothers who had nvd. whereas, there is not much difference in the distribution ratio between the two family types. possible logical explanation for this finding of our study can be that housewives mothers from lower income households are more inclined towards breastfeeding the infant for longer duration on account of the affordability issue. limitations: it was a hospital-based survey with a non-representative sample; so results cannot be generalized. conclusion the present study findings also show that there is an important role of an extended family system in enhancing the satisfactory knowledge level of mothers regarding breastfeeding. at home mothers and lower socio economic status has also shown to have a major contribution towards bf > 6 months’ duration. recommendations: results of the study warrant that another more precisely planned study should be conducted in this area with a representative sample and breastfeeding practices should be studied in detail along with the influencing factors. still, in the light of the present study results, health education programs/ sessions can be planned for mothers coming to this hospital; regarding improvement in their breastfeeding practices and enhancing the motivation level of mothers for optimal breastfeeding practices. funding source: none conflicts of interest: none references 1. kumar l, shahnawaz k, verma g, choudhary s.k, gupta a, singh j.b. knowledge, attitude, and practices of nourishing mothers about breastfeeding, attending urban health center: a cross sectional study from kishangang, bihar. jemds 2014; 3: 1681-90. 2. allen j, hector d. benefits of breastfeeding. new south wales public health bulletin 2005; 16:42-6 3. brown c.a, poag s, kasprzycki c. exploring large employer’s and small employer’s knowledge, attitudes, and practices on breastfeeding support in the workplace. j hum lac 2001; 17(1): 307-310. 4. mullany l.c, katz j, li y.m, khatry s.k, leclerq s.c, darmstadt g.l, tielsch j.m. breastfeeding patterns, time to initiation, and mortality risk among newborns in southern nepal. j nutr 2008; 138: 599-603. 5. who & unicef. global strategy for infant and young child feeding. geneva: world health organization: new york: united nations children’s fund; 2003. 6. amini m, salarki n, eshrati b, djazayery a. poor breastfeeding as a probable cause of childhood malnutrition: exploring mothers and care giver’s views on breastfeeding via a qualitative study in damavand, iran. razavi int j med 2013; 1(1): 30-4. 7. arora s, mcjunkin c, wehrer j, kuhn p. major factors influencing breastfeeding rates: mother’s perception of father’s attitude and milk supply. pediatrics 2000; 106: e67. 8. li r, darling n, maurice e, barker l, grummer-strawn l.m. breastfeeding rates in the united states by characteristics of the child, mother, or family: the 2002 national immunization survey. pediatrics 2005; 115: 317. 9. national institute of population studies (nips) pakistan and macro international inc. pakistan demographic and health survey 2012-2013, islamabad, pakistan. national institute of population studies and macro international inc.2009. 10. national institute of population studies islamabad pakistan. pakistan demographic and health survey 201718. 11. zeb j, mustajab m, zeeshan m, ullah s, qasim s, m, khalil m z. nursing mothers’ knowledge, attitude and practice towards breast feeding. pak j of med and dentistry 2017; 6(4): 39-43. 12. kumar s, jha sk, singh a, rawat cms, awasthi s, bano m, surana a. knowledge, attitude, and practices (kap) regarding breastfeeding: a community based cross sectional study from rural uttrakhand. health j 2015; 6(2): 17-22. 13. zakria m, afzal m, hussain m, gillani sa. assess knowledge, attitude, and practices of mothers regarding infant and child breastfeeding in the community. globus 2020; 9(2): 15-23. 14. kakati r, rahman s. colostrum feeding practices and its determinants among urban and rural mothers in kamrup assam, india. intj resmed sci 2016; 4(10): 4567-4572 15. ratnayake h, rowel d. prevalence of exclusive breastfeeding and barriers for its continuation up to six months in kandy district, sri lanka. int breastfeed j 2018; 13(36): 254-268. 16. altamimi e, al nsour r, aldaleen d, almajali n. knowledge, attitude, and practice of breastfeeding among working mothers in south jordan. workplace health safety 2017; 65(5): 210-218. saadia shahzad et al j aziz fatm med den college july december 2021; vol. 3, no. 2 45 kap study breastfeeding author’s contribution: m. hashir iqbal: concept, literature search, data collection, analysis, first draft writeup. namra noukhaiz: literature search, data collection, second draft write up. dr. saadia shahzad: study concept and design, analysis, final review, overall supervision. all authors are equally accountable for research work and integrity. received: 09 july 2020, revised received: 08 oct 2020, accepted: 27 oct 2020 j aziz fatm med den college january – june 2022; vol. 4, no. 1 1 original article accuracy of ultrasonography in predicting factors for difficult laparoscopic cholecystectomy muhammad raheem, sajid ali shah, s h waqar abstract objective: to determine the accuracy of ultrasound in predicting difficult laparoscopic cholecystectomy, keeping preoperative findings as gold standard. methodology: a cross sectional study was conducted from july 2018 to january 2019 at department of general surgery, pakistan institute of medical sciences islamabad. adult patients with diagnosis of cholelithiasis were included in the study by consecutive sampling, who underwent laparoscopic cholecystectomy. preoperative ultrasound parameters such as gallbladder wall thickness, size & number of gallstones, pericholecystic fluid, impacted stone and contracted gall bladder were studied. intraoperative difficulty of laparoscopic cholecystectomy was determined by the criteria as procedure time more than 60 minutes, dissection at calot’s triangle more than 30 minutes and tear of gallbladder. results: a total of 150 patients were included in the study with mean age of 41.4+9.9 years. there were 29(19.3%) males and 121(80.7%) females with male to female ratio of 1:4. preoperative ultrasonography (usg) findings such as gall bladder wall thickness >4mm, size of the stone ≥1 cm impacted gall stones, contracted gall bladder and presence of pericholecystic fluid were significantly (p value= 0.001) associated with difficult laparoscopic cholecystectomy. conclusion: in majority of the patients, preoperative ultrasonography is found as a good predictor of difficult laparoscopic cholecystectomy and should be used as a screening procedure. keywords: cholelithiasis, laparoscopic cholecystectomy, ultrasonography. introduction the gold standard in the treatment of symptomatic gallstones is laparoscopic cholecystectomy, which is one of the most regularly performed surgical operations globally.1 when compared to open cholecystectomy, literature demonstrates that laparoscopic cholecys tectomy is safer and more successful in terms of hospital stay, morbidity, recovery time, and cosmesis.2 it is associated to a 0.5% mortality rate and a 10% morbidity rate, respectively.3 there are many factors that make the laparoscopic surgery difficult like obesity, previous surgery in that area, multiple stones that may lead to spillage of stone into the common bile duct, gall bladder wall thickness of more than 4mm and dr. muhammad raheem mbbs postgraduate resident pakistan institute of medical sciences, isb dr. sajid ali shah mbbs, fcps assistant professor pakistan institute of medical sciences, isb dr. s h waqar mbbs, fcps, professor pakistan institute of medical sciences, isb correspondence: dr. s h waqar email: drshwaqar@szabmu.edu.pk presence of pericholecystic fluid.4 ultrasonography is the investigation of choice in gallbladder or biliary disease. preoperative abdominal ultrasonography is the most commonly used modality, as it is a low-cost, radiation-free, and non-invasive diagnostic approach.5 it is the gold-standard for the identification of extrahepatic biliary disorders and gall stone disease, with a sensitivity and specificity of 84 percent and 99 percent, respectively.6 preoperative ultrasonography can help to determine surgical problems or even the likelihood of a laparotomy conversion,4 despite that it is operator dependent. actual rates of conversion from the laparoscopic cholecystectomy to open cholecys tectomy recorded in the literature are highly diverse, ranging from 0% to 35%, despite the increase in surgical expertise.7,8 patients with a gall bladder wall thickness of more than 4 mm on ultrasonography are more likely to have a difficult operation or conversion to open , as well as a higher risk of bile duct injury or harm to the adjacent viscera,9 while the accuracy of presence of pericholecystic fluid on ultrasonography, is another factor of difficult laparoscopic surgery.10 the presence of multiple stones within the gall bladder on ultrasonography is another indicator of difficult laparoscopic surgery.11 surgeons can choose situations that are appropriate for their skills based on ultrasound j aziz fatm med den college january – june 2022; vol. 4, no. 1 2 findings, limiting operative complications and maximizing available operating time. it would be beneficial to have some reliable predictors of laparoscopic cholecystectomy conversion or complications. patients may be chosen for laparosc opic cholecystectomy and other high-risk operations with the potential for consequences. the aim of present study was to predict the diagnostic accuracy of ultrasonography in determining the factors that make laparoscopic cholecystectomy difficult. it might help the surgeon in better anticipation of the possible complications. secondly it will help the surgeon in better explaining the procedure its complications and possible conversion to open cholecystectomy to the patient and his/her relatives before surgery. in this way patient can be mentally prepared and he/she can adjust their expectations accordingly. methodology this cross-sectional validation study was conducted in department of surgery, pakistan institute of medical sciences, islamabad, including 150 patients from july 2018 to june 2019. sample size was calculated using who sample size calculator confidence level 95%. patient of both genders with age above 20 years with a diagnosis of cholelithiasis who admitted for laparoscopic cholecystectomy were included using non-probable consecutive sampling technique in this study. patients having cbd stones or any other cbd pathology, jaundice or abnormal liver function tests (lfts), acute cholecystitis, abnormal coagulation profile, and patients who had previously undergone upper abdominal procedures were excluded from the trial. informed consent was obtained from all of the patients recruited once the hospital ethical committee approved the study (f.1-1/2015/erb/szabmu/263). patients who fulfilled the inclusion criteria were selected from the opd of general surgery department and admitted to the ward for laparoscopic cholecystectomy. history was taken in detail from the patients and a thorough examination was performed. preoperative ultrasound was performed in all the patients by radiologist using the same probe (aplio 500, toshiba, japan). gallbladder wall thickness; number of gallstones, pericholecystic fluid, impacted stone and contracted gall bladder were the parameters studied on ultrasonography. the learning curve statistics do not apply to this study because the surgeon is experienced in laparoscopic surgery. intraoperative findings were recorded on specifically designed proforma. following criteria was set to objectively grade the operative findings as difficult laparoscopic cholecystectomy: • procedure time of more than 60 minutes (time taken from introduction of the verses needle or trocar until the retrieval of the gallbladder) • gallbladder tear during dissection, resulting in bile and stone leakage. • more than 30 minutes for dissection of gall bladder from the bed • calot's triangle took more than 30 minutes for dissection • any procedure that need conversion to the open statistical analysis: the data was examined using the spss version 24 computer-based statistical software. for the categorical variables like gender, number of gall stones, bladder wall thickness and presence of pericholecystic fluid, frequencies and percentages were determined. mean and standard deviations were calculated from continuous numerical variables like age. post stratification chi-square test was applied. p value less than 0.05 was considered statistically significant. diagnostic efficacy indices like sensitivity, specificity, positive predictive value (ppv), negative predictive value (npv) of ultrasonography were measured and accuracy for the ultrasonography was calculated by using the following standard formulas: sensitivity = tp/tp+fn x 100 specificity =tn/tn+fp x 100 positive predictive value = tp/tp+fp x 100 negative predictive value = tn/tn+ fn x 100 results a total of 150 patients were included in the study who underwent laparoscopic cholecystectomy. the mean age was 41.4±9.9 years (range 20 – 65 years). table 1: patients’ characteristics and parameters (n=150) items statistics n (%) age (years) mean ± sd median (range) 41.4±9.9 42 (20 – 60) gender female male 121 (80.7) 29 (19.3) bmi (kg/m2) <25 25 – 27.5 >27.5 102 (68) 14 (9.3) 34 (22.7) palpable gallbladder no yes 116 (77.3) 34 (22.7) operating time (minutes) mean + sd range 20.35 ± 17.62 8.31 – 90.7 conversion rate 07 (4.6) muhammad raheem et al j aziz fatm med den college january – june 2022; vol. 4, no. 1 3 there were 29 males (19.3%) and 121 females (80.7%), with male to female ratio was 1:4. (table 1) mean duration of surgery and postoperative hospital stay were 20.35 ± 17.62 minutes and 1.4 ± 0.5 days respectively. table 1 showed patients’ characteristics with conversion rate from laparoscopic surgery to open, while ultrasonographic findings are shown in table 2. table 2: preoperative ultrasonography (usg) findings of study population (n=150) usg findings n (%) peri-cholecystic fluid 7 (4.7) number of stones single multiple 08 (5.3) 142 (94.7) gallbladder wall thickness <4mm ≥4mm 132 (88) 18 (12) impacted stone 20 (13.3) contracted gallbladder 18 (12) size of the stone <1cm ≥1cm 122 (81.3) 28 (18.7) as demonstrated in table 3, preoperative ultrasound abnormalities such as gall bladder wall thickness >4mm, stone size ≥1 cm, contracted gall bladder, and table 3: relation of preoperative ultrasonography findings and difficult laparoscopic cholecystectomy (n=150) usg parameters findings laparoscopic cholecystectomy difficult n (%) not difficult n (%) total n p value gall bladder wall thickness ≤ 4mm > 4mm 18 (15.7) 31 (88.6) 97 (84.3) 04 (11.4) 115 35 .001* size of the stone <1cm ≥1cm 30 (24.6) 20 (71.4) 92 (75.4) 08 (28.6) 122 28 .004* gall stone mobility mobile impacted 99 (76.1) 20 (100) 31 (23.9) 0 (0.0) 130 20 .001* contracted gall bladder no yes 02 (1.5) 17 (94.4) 130 (98.5) 01 (5.5) 132 18 .001* pericholecystic fluid no yes 25 (20.3) 26 (96.3) 98 (79.7) 01 (3.7) 123 27 .001* p-value less than 0.05 considered significant table 4: diagnostic accuracy of ultrasonography findings in predicting difficult laparoscopic cholecystectomy (n = 150) usg findings diagnostic accuracy sensitivity (%) specificity (%) ppv (%) npv (%) accuracy (%) gall bladder wall thickness (>4mm) 89.4 99.2 94.4 98.4 98 size of the stone (≥1cm) 96.5 75 99.3 37.5 96 gall stone mobility (impacted) 40 100 100 76.9 80 contracted gall bladder 65 97.5 92.9 84.5 86.7 pericholecystic fluid 75 99.3 89.7 98.6 98 ppv=positive predictive value, npv=negative predictive value, usg = ultrasonography presence of pericholecystic fluid were strongly linked with complicated laparoscopic cholecystectomy. the presence of the pericholecystic fluid on ultrasonography and gall bladder wall thickness of more than 4mm were the most reliable predictors of a difficult laparoscopic cholecystectomy, followed by the size of the stone and a contracted gall bladder, as shown in table 4. sensitivity, specificity, positive predictive value, negative predictive value and diagnostic accuracy of gall bladder wall thickness of more than 4mm and pericholecystic fluid on ultrasonography were predictors of the difficult laparoscopic cholecystectomy showed 89.4%, 99.2%, 94.4%, 98,4%, 98% and 75%, 99.3%, 85.7%, 98.6%, 98% respectively; while number of gall stones on ultrasonography showed sensitivity 96.5%, specificity 75%, ppv 99.3% npv 37.5% and 96% diagnostic accuracy. discussion cholelithiasis is one of the most frequent digestive problems. gallstones are typically asymptomatic (>80% of the time), and the prevalence of gallstones varies greatly around the globe.12 due to benefits of reduced postoperative morbidity, safety, and success, laparoscopic cholecystectomy has become the gold standard treatment for symptomatic gallstones.13 it is now the most commonly performed operation by general surgeons. currently, the laparoscopic cholecystectomies account for about 80% of cholecystectomies.14 aim was to determine if there were any pre-operative abdominal ultrasonographic parameters that could accurately predict the likelihood of difficulty and problems during laparoscopic cholecystectomy. when there was an acutely inflamed or gangrenous gallbladder, dense adhesions at calot's triangle, fibrotic and contracted gall bladder, the surgeons encountered difficulties in laparoscopic cholecystectomy. male sex, advanced age, obesity, acute cholecystitis attacks, previous abdominal surgery, and certain ultrasonographic abnormalities, such as thickening gall bladder wall, distended gall bladder, pericholecystic fluid collection, and impacted stone, are all risk factors that make laparoscopic operation difficult. although generally safe and uneventful, laparoscopic cholecystectomy might be challenging at times. the majority of the country's novice laparoscopic surgeons use relatively basic instruments and infrastructure. it's also possible that senior laparoscopic surgeons won't be available. with increasing expertise, the selection criteria for laparoscopic cholecystectomy have gotten more lenient. accuracy of ultrasonography in difficult laparoscopic cholecystectomy j aziz fatm med den college january – june 2022; vol. 4, no. 1 4 old age has been identified as a substantial risk factor for the complicated laparoscopic cholecystectomy in some investigations15 and choose the age of 50 years as cut off for this purpose. because the majority of the patients in this study were under the age of 50, age had no bearing on intraoperative difficulties. this finding is in line with that of gupta et al, while saleem aa et al discovered a strong link between age higher than 50 years and surgical difficulty.16,6 most of the patients (80.7%) in this study were females. the effect of estrogen and progesterone on biliary cholesterol levels and gallbladder motility has been linked to a higher prevalence of gallstones in women.17 the connection between male sex and difficult cholecystectomy is debatable. according to several studies, male gender may be a risk factor for complicated cholecystectomy. males may be detected late since cholelithiasis is thought to be mostly a disease of females. due to frequent attacks of inflammation before diagnosis, it may result in substantial adhesions. males had a considerably higher conversion rate than females, according to nidoni et al (p = 0.034, 95 percent confidence interval). 18 the conversion rate from laparoscopic to open cholecystectomy varies between 7% and 35% globally.19 in this study, the overall conversation rate was 4.6 percent; all cases had mostly comparable prognostic variables, such as palpable gb, pericholecystic collection, increased gb wall thickness, and a bmi of more than 25, while gender and age had no bearing on conversion. this finding is in consistent with bourgouin et al (4.3%).20 this low conversion rate may be attributed to the expertise of the operating surgeon. several prediction models for a difficult lc have been presented but these are based on subjective assessment of difficulty made by surgeon that he encounters intraoperative. however, because these evaluations are based on a surgeon's experience and usual practice, they are difficult to transmit between institutions.21 so findings of ultrasonography have been used as predictors for difficult laparoscopic cholecystectomy. gall bladder has been identified in studies as a predictor of difficult surgery.22 gall bladder wall thickness is one of the most researched parameters, and it can be assessed with high precision using ultrasonography.23 gall bladder detachment from its bed is more difficult when the thickness of wall of the gall bladder is increased; thicker gall bladder walls make grasping and manipulating the gall bladder more difficult, as well as making dissection at calot's triangle and the gall bladder bed more difficult.6 in this study, we discovered a significant link (p 0.001) between the gall bladder wall thickness and the complex surgery which is comparable to other studies. the presence of pericholecystic fluid on ultrasonography was found to be a predictor for the difficult laparoscopic cholecystectomy in the study; this was present in 27 (18%) patients and in 26 cases, laparoscopic cholecystectomy was found difficult. similar results were described by chindarkar h et al and nidoni et al in their studies.2,18 another important indicator that has a good predictive value is a stone impacted at the neck. because of the distension of the gall bladder and the thick gall bladder wall, an impacted stone at the neck of the gall bladder causes some technical issues in the laparoscopic cholecystectomy. we found stone impacted in 20 (13.3%) patients and all were difficult on surgery. the impacted stone caused mucocele, which made it difficult to grasp the gallbladder's infundibulum for retraction during dissection, resulting in difficult operation. this result is in consistent with other studies.24 many studies have discovered a statistical link between the size of stones and the conversion of laparoscopic cholecystectomy to open cholecystectomy.2 the same is found in the present study, but jansen et al showed that stones larger than 20 mm were associated with a higher chance of conversion.25 in this study, a 10 mm gall bladder calculus is used as a cutoff size. twenty (71.4%) out of the 28 cases with calculi larger than 10 mm had difficult laparoscopic surgery, while the remaining eight (28.6%) did not. a much higher proportion of cases with a larger calculus had a higher likelihood of difficult surgery. limitations: major limitations of ultrasound are that it is operator dependent, experience of sinologist, difficulty in obese patients and difficulty with contracted gall bladder. conclusion in the vast majority of instances, preoperative ultrasonography is an excellent predictor of difficulty in laparoscopic cholecystectomy and should be used as a screening technique. this can help the surgeon anticipate any potential problems during surgery, allowing for better pre-operative planning and patient counseling, and lowering overall morbidity and complications. conflict of interest: none funding source: self. muhammad raheem et al j aziz fatm med den college january – june 2022; vol. 4, no. 1 5 disclaimer: this article is based on the dissertation of dr muhammad raheem, postgraduate student, for fcps in surgery. references 1. sharma m, muthuraman s, anand s, minhas ss. preoperative ultrasonography as a predictor of difficult laparoscopic cholecystectomy: a prospective study. ann. int. med. den. res. 2020; 6(3):rd01-rd04. 2. chindarkar h, dumbre r, fernandes a, phalgune d. study of correlation between pre-operative ultrasonographic findings and difficult laparoscopic cholecystectomy. int surg j 2018; 5(7):26052611. doi: http://dx.doi.org/10.18203/2349-2902.isj20182782 3. saber a, abu-elela st, shaalan km, al-masry ar. preoperative prediction of the difficulty of laparoscopic cholecystectomy. j surg surgical res. 2015; 1(1): 15-18. doi: 10.17352/2454-2968.000004015 4. stogryn s, metcalfe j, vergis a, hardy k. does ultrasonography predict intraoperative findings at cholecystectomy? an institutional review. can j surg 2016; 59(1):12-8. doi: 10.1503/cjs.005915. 5. saleem aa, hassan aa. evaluation of preoperative predictive factors for difficult laparoscopic cholecystectomy in comparison with intraoperative parameters. egypt j surg 2018; 37(4): 504-511. doi: doi: 10.4103/ejs.ejs_66_18 6. lal p, agarwal pn, malik vk, chakravarti al. a difficult laparoscopic cholecystectomy that requires conversion to open procedure can be predicted by preoperative ultrasonography. jsls 2002; 6:59–63. 7. alan s, yew hu r, menon r. risk factors for conversion of laparoscopic cholecystectomy to open surgery a systematic literature review of 30 studies. am j surg 2017; 214 (5): 920-930. doi: 10.1016/j.amjsurg.2017.07.029. 8. amin a, haider m, aamir is, khan ms, choudry uk, amir m, sadiq a. preoperative and operative risk factors for conversion of laparoscopic cholecystectomy to open cholecystectomy in pakistan. cureus 2019; 11(8): e5446. doi:10.7759/cureus.5446. 9. gupta a n, gyan r, binita g, poras c. validation of a scoring system to predict difficult laparoscopic cholecystectomy. int j surg 2013; 11(9):1002-1006. doi: 10.1016/j.ijsu.2013.05.037. 10. qureshi tj, khan au, ashfaq a, abid kj. to determine the diagnostic accuracy of gallbladder wall thickness and presence of pericholecystic fluid in predicting the need for conversion of laparoscopic cholecystectomy to open cholecystectomy in patients with cholelithiasis. pak j med health sci. 2016; 10:1031-4. 11. kreimer f, cunha dj, ferreira cc, rodrigues tm, fulco lg, godoy es et al. comparative analysis of preoperative ultrasonography reports with intraoperative surgical findings in cholelithiasis. arq bras cir dig. 2016; 29(1): 26–29. doi: 10.1590/0102-6720201600010007 12. rao ks, meghavathu gn, rao gs, prasad hrt. clinical study of gallstone disease and treatment options. j evol med dent sci 2015; 4:13841–13848. doi:10.14260/jemds/2015/1972 13. faraht ms, elmaleh hm, abdelghani hassan wm, abdelrahim hs preoperative prediction of difficult laparoscopic cholecystectomy: a scoring method. med j cairo univ 2021; 89(4): 1659-1667. 14. majumder a, altieri ms, brunt lm. how do i do it: laparoscopic cholecystectomy. ann laparosc endosc surg 2020; 5:15 | http://dx.doi.org/10.21037/ales. 15. lee nw, collins j, britt r, britt ld. evaluation of preoperative risk factors for converting laparoscopic to open cholecystectomy. am surg 2012; 78:831-3. 16. gupta n, ranjan g, arora mp, goswami b, chaudhary p, kapur a, et al. validation of a scoring system to predict difficult laparoscopic cholecystectomy. int j surg 2013; 11:1002-6. doi: 10.1016/j.ijsu.2013.05.037 17. sharma r, sachan sg, sharma sr. preponderance of gallstone in female. world journal of pharmacy and pharmaceutical sciences. 2013, 2(6): 5871-5877. 18. nidoni r, udachan tv, sasnur p, baloorkar r, sindgikar v, narasangi b. predicting difficult laparoscopic cholecystectomy based on clinicoradiological assessment. j clin diagn res 2015; 12: 9:pc09. doi: 10.7860/jcdr/2015/15593.6929. 19. thyagarajan m, singh b, thangasamy a, rajasekar s. risk factors influencing conversion of laparoscopic cholecystectomy to open cholecystectomy. int surg j 2017; 4(10): 3354-3357. doi: http://dx.doi.org/10.18203/2349-2902.isj20174495 20. bourgouin s, mancini j, monchal t, calvary r, bordes j,balandraud p. how to predict difficult laparoscopic cholecystectomy? proposal for a simple preoperative scoring system. am j surg 2016; 212(5): 873881.doi:10.1016/j.amjsurg.2016.04.003 21. wennmacker sz, bhimani n, van dijk ah, hugh tj, de reuver pr. predicting operative difficulty of laparoscopic cholecystectomy in patients with acute biliary presentations. anz j surg. 2019; 89(11): 1451-1456. doi: 10.1111/ans.15493. epub 2019 oct 22. pmid: 31642165; pmcid: pmc6899702. 22. zaineb t, hassaan a, hajirah k, hassan m, syeda ameera n, javed m et al . preoperative factors associated with difficult laparoscopic cholecystectomy. biomed j sci & tech res 2021; 33(1)-2553125536. doi: 10.26717/bjstr.2021.33.005349 23. sharma b, bhati t, gupta v. predictive role of preoperative ultrasonography in laparoscopic cholecystectomy. j mahatma gandhi univ med sci tech 2017; 2(2):78-80. doi: 10.5005/jpjournals-10057-0040 24. shaban h, alsehily a, elhadary mk, elkerkary ma. evaluation the effectiveness of pre-operative prediction scoring system for difficult laparoscopic cholecystectomy. j surg 2020; 5: 1297. doi: 10.29011/2575-9760.001297. 25. jansen s, jorgensen j, caplehorn j, hunt d. preoperative ultrasound to predict conversion in laparoscopic cholecystectomy. surg laparosco endosco percutaneous techniq. 1997; 7(2):121-3. authors’ contribution: dr. muhammad raheem study design and concept, the acquisition, analysis, or interpretation of data for the work; drafting the manuscript revising critically for important intellectual content dr. sajid ali shah study design and concept, data collection and analysis, or interpretation of data, manuscript writing, revising it critically for important intellectual content dr. s h waqar study design, interpretation of data for the work; drafting the manuscript or revising it critically for important intellectual content all authors participated in study design and writing manuscript and agree to be accountable for accuracy, integrity of all aspects of the work. date of submission: 12-12-2021 revised: 07-01-2022 accepted: 11-01-2022 accuracy of ultrasonography in difficult laparoscopic cholecystectomy j aziz fatm med den college january – june 2022; vol. 4, no. 1 12 original article association of imposter phenomenon and burnout with mode of education among medical students of pakistan farhat ijaz, uswah bokhari, sehar khauteja khan, uswah shoaib, sana tariq, rana zaid haris, rana khurram aftab abstract objectives: to determine the association of imposter syndrome and burnout in medical students during online and face-face education in pakistan. methodology: a cross-sectional study was conducted at cmh lahore medical college and institute of dentistry during the months of may to june 2021. participants belonged to any academic year of either the mbbs (a fiveyear program) or bds (a four-year program) disciplines were included. students of nursing and allied health sciences were excluded. the sample size was 282. non-probability convenient sampling technique was used to enroll participant after taking ethical approval by a local ethical review board of cmh lahore medical college. oldenburg burnout inventory was used for identifying burnout and clance impostor phenomenon scale was used for identifying imposter characteristics in students. data was analyzed using spss version 22. categorical data are shown as percentages and frequencies and compared by chi-square test. p-value < 0.05 was taken as statistically significant. results: the mean impostorism score was higher in face-to-face (in-class education) education however, analysis of the clance impostor phenomenon scale (cips) showed no significant association of imposter characteristics with the mode of education with a p-value of 0.053. the mean score for total burnout was higher during online education. the difference in burnout, exhaustion, and disengagement during the online mode of education and faceto-face mode of teaching was significant with a p-value of 0.001, 0.001, 0.002 respectively. conclusion: imposter characteristics are an intrinsic factor not affected by external environment. however, burnout is higher during online education which can be overwhelming and should be taken into consideration when designing curricula. keywords: imposter phenomenon, burnout, online education, traditional education. introduction burnout, which is characterized by emotional distress and cynicism, has been a source of debate in recent years, particularly among medical students and physicians. medicine requires motivated, competitive students who can cope with rigorous schooling, high ___________________________________________________________ dr. farhat ijaz1 mbbs, fcps associate professor, uswah bokhari2 student 5th yr. mbbs sehar khauteja khan3 student 5th yr. mbbs uswah shoaib4 student 5th yr. mbbs sana tariq5 student 5th yr. mbbs rana zaid haris6 student 5th yr. mbbs 1-6 cmh lahore medical college & institute of dentistry lhr dr. rana khurram aftab, mbbs, mphil punjab institute of cardiology, lhr. correspondence to: dr. farhat ijaz email: farhat_khurram_rana@cmhlahore.edu.pk levels of stress, and disappointments. these characteristics, unfortunately, also contribute to the development of burnout. insomnia, increased drinking, poor marital and family issues are all common symptoms of burnout. 1 this has become much more alarming because of the pandemic, particularly among younger people.2 medical students are in danger of weariness and burnout as a result of increased stress and anxiety especially due to increased screen time owing to tele-education during lockdowns. another topic gaining popularity recently is imposter phenomenon, characterized by chronic feelings of selfdoubt intellectually.4 these individuals consider are skeptical about their intelligence and competency which leads lack of accomplishment and incompetence.5 a study among internal medicine residents, 43.8% were found to have imposter syndrome while only 12.5% reported burnout.4,6 majority of medical students on the clinical phase of their training indicate moderate-to-strong impostor feelings.7 literature on imposter syndrome regarding education during the pandemic is limited. burnout and mailto:farhat_khurram_rana@cmhlahore.edu.pk j aziz fatm med den college january – june 2022; vol. 4, no. 1 13 imposter phenomenon can significantly impact medical education. those suffering are less likely to speak up, clarify their queries, or volunteer answers and information, especially during digital education.5 due to the surge in covid-19 most schools and universities closed and shifted from face-to-face teaching to online education, also called tele-education, as a simple and convenient solution. education was continued using digital platforms including zoom, skype, google classroom, pre-recorded video lectures, etc. however, as described by mohammad h rajab et. al. this solution came with many challenges including problems related to communications, student assessments, pandemicrelated anxiety or stress, time management, and problems with technology.8 tele-education negatively impacts mental health and increases cynicism as shown by panagiotis zis et al.9 this suggests that there is a need for consideration of a curriculum that takes into account these factors, especially during the era of teleeducation. implementing a mental health education course in the medical curriculum has shown to decrease academic burnout and psychological distress.10 this study seeks to explore imposter syndrome and burnout in medical students during online and face-face education in pakistan. methodology this was a cross-sectional study was done at cmh lahore medical college, pakistan during may to june 2021. participants, both male and female with age ranges, between 18-25years, belonging to any academic year of either the mbbs (a five-year program) or bds (a four-year program) discipline were included in the study. students of other disciplines i.e. nursing and allied health sciences were excluded. the participants were invited to fill the questionnaire after taking ethical approval from local ethical board of cmh lahore medical college (141/erc/cmhlmc) by the non-probability convenience sampling technique. the estimated population size was 1050 and the calculated sample size was 282 using the rao soft formula. the confidence interval is 95% and the margin of error is 5%.microsoft forms were used to collect data by sending the link for the form via whatsapp. the questionnaire had 46 items divided into 3 sections; demographic profile, oldenburg burnout inventory, and clance impostor phenomenon scale respectively. the demographic profile (10 items) inquired regarding age, gender, discipline and year of study, the preferred mode of education, current mode of education, and challenges faced during online learning. oldenburg burnout inventory (olbi), a 16-item scale was used to assess burnout.11 the alpha cronbach statistic for emotional exhaustion is 0.67 and for disengagement from work is 0.61. the combined alpha cronbach statistic is 0.74.12 olbi measures two parameters; exhaustion and disengagement, each with 8 questions on a four-point likert scale. exhaustion refers to feelings of emptiness, overwork, a strong need for rest, and physical exhaustion while disengagement refers to distancing oneself from the objects and content of one's work.13 total scores for burnout ranged from 16 to 64. the degree of burnout was categorized as low, moderate, and high with a score <44, score 44-59, and score >59 respectively. exhaustion was categorized as low, moderate, and high; score <21, score 21-29, and score >29 respectively. disengagement was categori zed as low moderate and high with a score <24, score 24-31, and score >31 respectively.14 clance impostor phenomenon scale (cips), a 20-item 5-point likert scale was used to quantify imposter characteristics.15 the total score was additively ranging between 20 to 100. a score < 40 indicated few impostor characterist ics; 41-60, moderate impostor characteristics; 61-80 frequent impostor experiences; and more than 80, intense impostor experiences. a score of 62 or higher indicated that the individual had imposter syndrome. the instrument has high internal reliability with cronbach statistic of α=0.92.16 statistical analysis: all data were analyzed using spss software (version 26; ibm). results have been presented in frequency and percentages. the chisquare test was used for the comparison of categorical variables. p-value < 0.05 is statistically significant. results in this study, the total number of participants was 282, out of which 56% were males and 44% were female students. the mean age ± sd of the study population was 20.66 ± 1.71years. the participants from the mbbs discipline were 85.1% and that of the bds discipline were 14.9%. distribution of students of basic sciences, preclinical and clinical sciences are shown in the table 1. most of the students preferred combined face-to-face and online education (67.4%). however, the current mode of education was online for 42.4% of the population and face-to-face (in-class education) for 57.8% of the population. the demographic profile is shown in table 1. the distribution of impostor scale scores for the mode of education is shown in figure 1. the mean impostor score was 64.23 ± 15.66 (frequent impostor characteristic) for the entire sample. farhat ijaz et al j aziz fatm med den college january – june 2022; vol. 4, no. 1 14 table 1: demographic profile of study population (n=282) variable population n (%) gender male 158(56%) female 124(44%) discipline mbbs 240(85.1%) bds 42(14.9%) year of study basic sciences 142(50.4%) pre-clinical year 38(13.5%) clinical years 102(36.2%) preferred mode of education face-to-face (in class education) 10(3.5%) combined face-to-face (in class education) and online education 190(67.4%) online education 82(29.1%) current mode of education face-to-face (in class education) 163(57.8%) online education 119(42.4%) it was higher in face-to-face (in class education) education. the percentage of the population meeting the threshold for imposterism was 55.0% with 34.0% in face-to-face education and 20.9% in online education. analysis of the clance impostor phenomenon scale (cips) found no significant association of imposter characteristics with the mode of education with a p-value of 0.053. the detail is shown in table 2. the mean score for total burnout was 33.63 ± 7.20 for the entire population. it was significantly higher during online education as compared to face to face teaching (p value = 0.001) as shown in table 3. figure1: imposter score in two modes of education in medical students. (n face to face =164 and n online = 118) table 2: degree of imposter phenomenon and its association with mode of education (n= 282) imposter characteristics mode of education n (%) p-value online (n=118) face-to-face (n=164) 0.053 few 11(9.3) 10(6.1) moderate 49(41.5) 56(34.1) frequent 46(39.0) 59(36.0) intense 12(10.2) 39(23.8) p value ≤ 0.05 taken significant, determined by chi-square the mean score for exhaustion was 21.50 ± 4.18 for the entire population. exhaustion was comparatively higher in traditional (face-to-face) education than online education (p value =0.002) as presented in table 3. the mean score for disengagement was 12.12 ± 4.64 for the entire population. disengagement was significantly higher in online education than traditional table 3: degree of burnout and its association with mode of education (total n=282, online=118, face to face= 164) burnout component mean score degree of burnout n (%) pvalue high moderate low total burnout (n=282) 33.63±7.20 2(0.71) 24(8.51) 256(90.78) online education 35.49±9.14 2(1.7) 24(20.3) 92(78.0) 0.001* face-to-face (in class education) 32.29±4.90 1(0.6) 1(0.6) 162(98.7) disengagem ent (n=282) 12.12±4.64 1(0.35) 10(3.5) 271(96.09) online education 14.88±5.88 1(0.84) 10(8.5) 107(90.6) 0.001* face-to-face (in class education) 10.14±1.68 1(0.6) 1(0.6) 162(98.7) exhaustion (n=282) 21.50±4.18 14(4.9) 147(52.1) 121(43.06) online education 20.61±4.20 2(1.7) 52(44.1) 64(54.2) 0.002* face-to-face (in class education) 22.15±4.06 12(7.3) 95(57.9) 57(34.8) p value ≤ 0.05 taken significant, determined by chi-square (face-to-face) education with p value 0.001* (table 3). the key outcomes include a higher mean total burnout and disengagement in online education but higher exhaustion in traditional education. there was a significant association between burnout, exhaustion, and disengagement and mode of education. imposter phenomenon and mode of education showed no correlation. discussion this study was conducted to search for an association of burnout and impostor syndrome traits with discipline, year of study, and gender. it is seen that frequency of medical students with low total burnout is higher in face-to-face education than the online education which means that the students might have imposter phenomenon and burnout with mode of education j aziz fatm med den college january – june 2022; vol. 4, no. 1 15 had a lower burnout in the face-to-face education as they were less exposed to gadgets and lectures were more interactive which led to the fixation of attention to the actual lectures. these findings are consistent with mheidly et al.3 however, students were exhausted more in physical classes with a higher degree of burnout which might be because of constant lack of sleep, pretending to stay alert even though they are tired, inability to procrastinate, or roam around which leads to emotional instability.17 individuals having few or moderate imposter characteristics have a lower degree of burnout in domains of total burnout, exhaustion, disengagement, as seen by statistically significant results, which implies that the lesser the student is conscious of his activities or professional conduct, the better he works. hence it shows having imposter characteristics may induce a higher degree of burnout, eventually leading him to abandon his job due to increased mental and physical stresses.18 it is worrisome to observe that females have a higher risk of having intense imposter characteristics (13.84%) which lead to exhaustion caused by a high degree of burnout. this is similar to two studies, the first one conducted at university of kansas medical center in which female students compared themselves more to others.7 the other study was conducted in lahore at a private medical college.19 this certainly needs to be investigated to avoid any unprecedented, undiagnosed mental diseases which may hinder the medical department as women are a big part of the workforce there. it may be because females have an inherent ability to overthink others’ perceptions, and also are more involved in maintaining self-image; this has also been noticed in another study by beth levant.7 as the year of study progresses with its new challenges, the more the individuals get intense imposter characteristics, leading to a higher degree of exhaustion. this is because as soon as the professional life comes closer, the students tend to become over conscious about their current ranking in order to avoid future ordeals, which may perhaps lead them towards problems with lower self-esteem, work related stress and emotional distress.20 mental health problems are on the surge as the pandemic of covid-19 aggravates. the most susceptible group amongst people are the medical students who have an intrinsic sense of competitiveness, ego, and hard work. ever since day one of being admitted to medical colleges, medical students are enforced to work hard in various tests, clinical exams. this leads to the development of traits involving rigorous competitiveness and a hidden ego. every student works hard to an extent that leads to a depressed, exhausted soul if one does not meet the demands of the profession. every day there is a new challenge to solve, which eventually leads to exacerbation of the underlying undiagnosed burnout.21 covid-19 has led to a worldwide pronounced quarantine to avoid the spread of infection, which meant the closure of medical schools as well. it might seem feasible on the outside, but the education and clinical skills of students were compromised, which further led to an increased sense of insecurity about themselves despite of whatever efforts they did, in online lectures, regarding the field of medicine.22 limitations: the limitations of this study were that it was restricted to a particular medical college. it is a cross-sectional study with a small sample size; bigger sample size and more students from different medical colleges will give more accurate results. moreover, a comparison between public and private sector medical colleges may also better help establish an association between burnout and the imposter phenomenon. association of age and degree of burnout could have been done as well to see from which age the intensity of imposter symptoms begins so that it could be caught there and treated especially through tailored and customized approaches. as students continue experiencing more severe imposter characteristics, if untreated it might affect their clinical skills and future competencies as well. conclusion significantly higher proportion of the imposter characteristics, burnout and disengagement was obser -ved in medical students during online education. however, exhaustion was comparatively higher in traditional(face-to-face) education. recommendations: in short, it could be said that once a student begins his or her education, proper counseling must be done to avoid future low self-esteem and confidence problems. medical 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2008;44(5):1270-1278. https:// doi. org/10.1016/j.paid.2007.11.023 17. lucchetti g, damiano rf, dilalla lf, lucchetti al, moutinho il, da silva ezequiel o, et al. cross-cultural differences in mental health, quality of life, empathy, and burnout between us and brazilian medical students. academic psychiatry. 2018;42(1):62-67. 18. alrayyes s, dar uf, alrayes m, alghutayghit a, alrayyes n. burnout and imposter syndrome among saudi young adults: the strings in the puppet show of psychological morbidity. saudi med j. 2020;41(2):189-194. doi: 10.15537/smj.2020.2.24841. 19. qureshi ma, taj j, latif mz, zia s, rafique m, chaudhry ma. imposter syndrome among pakistani medical students. annals of king edward medical university, 23(2).106-110. https://doi.org/10.21649/akemu.v23i2.1647 20. rosenthal s, schlussel y, yaden m, desantis j, trayes k, pohl c, hojat m. persistent impostor phenomenon is associated with distress in medical students. family medicine. 2021;53(2):118-122. 21. muzafar y, khan hh, ashraf h, hussain w, sajid h, tahir m, rehman a, sohail a, waqas a, ahmad w. burnout and its associated factors in medical students of lahore, pakistan. cureus. 2015;7(11):e390. doi: 10.7759/cureus.390. 22. newman na, lattouf om. coalition for medical education a call to action: a proposition to adapt clinical medical education to meet the needs of students and other healthcare learners during covid‐19. j card surg. 2020;35(6):11741175. doi: 10.1111/jocs.14590. imposter phenomenon and burnout with mode of education http://www.psicopolis.com/burnout/bumesur.pdf https://doi.org/10.21649/akemu.v23i2.1647 j aziz fatm med den college january – june 2022; vol. 4, no. 1 17 author’s contribution: dr. farhat ijaz overall supervision, data analysis, data interpretation, drafting, revision & final approval uswah bokhari literature search, study design & concept, questionnaire design, data interpretation sehar khauteja khan literature search, data collection, drafting uswah shoaib literature search, study design & concept, questionnaire design, data interpretation sana tariq literature search, data collection, drafting rana zaid haris literature search, data collection, drafting dr. rana khurram aftab overall supervision, data analysis, data interpretation, drafting, revision & final approval. all authors are equally accountable for accuracy, integrity of all aspects of the research work. date of submission: 30-09-2021 revised: 15-01-2022 accepted: 19-01-2022 farhat ijaz et al j aziz fatm. med den college january – june 2023, vol,5. no.1 3 original research antimicrobial susceptibility of plant extracts on isolated microorganism from diabetic and non-diabetic population syeda aatika batool, farheen ansari, sidra gondal, mahreen mahmood, kainat asmat introduction egyptians were the first who discovered diabetes and featured it through polyuria and weight loss. greek physician aertaeus designed the term diabetes mellitus (dm). diabetes meaning is “to pass through’’ and mellitus is the latin word for syeda aatika batool, m.phil lecturer bahria town school of nursing, lhr pakistan farheen ansari, mphil, phd associate professor the university of lahore, pakistan. sidra gondal, bsn, mph lecture akhtar saeed college of nursing lahore. pakistan mahreen mahmood, bds, mphil dental surgen thq, dipalpur. pakistan kainat asmat, phd scholor assistant professor shifa tameer e millat university, isd. pakistan correspondence: syeda atika batool aatikabaqari@gmail.com “honey’’ (sweetness) owing to the increased amount of sugar in the urine. it is surveyed and estimated that the prevalence of diabetes in adults has been increasing from 4% in 1995 to 6.4 % by 2025. the immune system of man is seriously disturbed and many abnormalities and complications are due to diabetes. it may lead to high saccharide concentration in the urine. many types of disease-causing microbes can grow on this particular medium. the miserable infection condition and its risks may develop in diabetes patients at a greater rate. 1 diabetics have a 10-fold increased risk of uti as compared to non-diabetics and also a longer hospitalization. 2 all over the world, urinary tract infections of acute nature occur in females and it becomes costly to take care of annually in pakistan. it is estimated that 65% of all females experience oneor two-times urinary tract infections within their lifetime and 25 to 30% of females experience this infection repeatedly. 3 early marriages are considered a factor for uti in slim girls in pakistan. bacteria of abstract objectives: to isolate and characterizing microorganisms from diabetic and non-diabetic patients and assessing the antimicrobial activity of isolate extracts from citrus sinensis and psidium guajava. methodology: experimental study of one year and six month duration from may 2016 to may 2018 conducted in microbiology laboratory university of lahore, pakistan. convenient sampling was done by collecting the urine sample at random from 250 persons in the pattoki community. all the urine samples from diabetic and non-diabetics were cultured separately and after biochemical confirmation of microorganisms, the disc diffusion method was used for carrying out an antimicrobial activity. results: a total of 105 samples, were found to have positive urine cultures. among these positive urine culture samples, 75 were diabetic and 30 were non-diabetics. the bacterial isolate most commonly found among diabetics was e.coli followed by the presence of staphylococcus aureus, klebsiella pneumoniae, pseudomonas aeruginosa, proteus vulgaris respectively. minimal inhibitory concentration (mic) of different parts of plant extracts against isolated bacteria from diabetics showed that the highest sensitivity was shown against peel, leaves and seed extracts of citrus sinensis and psidium guajava while the least sensitivity was shown against the stem and root extracts of these plants. moreover, antibiotic sensitivity tests of isolated microbes showed that the highest resistance is found against augmentin and tetracycline while the most sensitive drug for isolates was found to be chloramphenicol. conclusion: from the results, it is concluded that leave extract of psidium guajava and peel extracts of citrus sinensis showed effective results against bacterial pathogens and could serve as a good alternate source of antibacterial agents. keywords: urinary tract infection, asymptomatic bacteriuria, psidium guajava, citrus sinensis, diabetics mailto:aatikabaqari@gmail.com syeda atika batool et al j aziz fatm. med den college january – june 2023, vol,5. no.1 4 variable pathogenicity like e. coli is most frequently responsible for urinary tract infections. different other species like klebsiella, enterococcus, proteus and enterobacter spp. are also responsible for causing utis. staphylococcus aureus, and streptococcus group b are mostly observed for the enhanced ratio of uti patients. 4 multidrug resistance of e. coli is due to geographic changes among other strains. e. coli is responsible for more than 82% of less complicated community acquired utis, especially in females below 50 years of age. the prevalence of urinary tract infections (utis) and asymptomatic bacteriuria (asb) increases in patients with diabetes mellitus (dm). people with diabetes are also at higher risk for complications of uti and utis caused by fungi. 5 diabetics are reported to have a three to four times higher risk of utis in comparison to non diabetics. one reason suggested behind this increased bacterial growth is a dysfunctional bladder that promotes static pools of urine due to poor contraction. while another reason is bacterial growth and colonization promoted due to hyperglycemic urine. 6 the synergistic effect of the extracts of plant parts containing many phytochemicals proved as best antimicrobial agents. these activities of the plant extracts (antimicrobial and other biological) depend upon the origins and extraction of plant parts. in traditional medicine, one of the most effective herbs is from the genus citrus and further belongs to the family rutaceae. in asia, tropical and subtropical areas support the growth of the citrus genus. 7 major activities recognized in the citrus species are antimicrobial, physiological, and pharmacological activities, medicinal, antioxidant, antinflammatory, hypoglycaemic and anticancer. 8 rich sources of biologically active compounds are essential oils with antioxidant, antibacterial, insecticidal, antiviral and antifungal properties. 9 the citrus peel contains bioflavonoids (naringin and hesperidin) that result in the diabetic kineticism of orange. 10 although many studies have been done on the antioxidant and antibacterial effect of juice and edible parts, there is meager literature on the wastes of citrus fruits of lemon and oranges of different varieties. 11 plants in the family myrtaceae have medicinal properties too such as guave or psidium guajava, eucalyptus, allspice and clove. guava is a native fruit of tropical america, but many tropical and subtropical countries cultivate it as edible fruit. 12 according to the literature, guava leaves also have an anti-diabetic effect so they could prove to be the best source of drug used for utis in diabetics. 13,14 previously prevention and treatment of diarrhea were achieved by using guava leaves, roots and fruits. guava leaves were detected to have a high level of antibacterial activity. 15 significant antibacterial activity of guava reported in several studies against diarrhea-causing and food-borne bacteria such as e. coli, salmonella & shigella species, staphylococcus species, clostridium species, bacillus species, and pseudomonas species as food spoilage bacteria. guava leaves and fruit juice tested in the treatment of many infections. 16 psidium guajava leaves, fruit, bark, and roots proved by pharmacological investigations that they possess anti-inflammatory, antibacterial, analgesic, antipyretic, hypoglycemic, cns depressant and spasmolytic activities. 17 the synergistic effect of the extracts of plant parts containing many phytochemicals proved as best antimicrobial agents 18 . there is a negative effect on microbial cells by plant-derived substances through various mechanisms of action as these substances attack the phospholipid bilayer of the cell membrane and destroy the enzyme system. 18 moreover, there is an increased popularity in the application of natural antimicrobials due to a series of issues related to the control of microorganisms and as a source of pharmaceutical active compounds. 19,20 the objectives of this study were to isolate and characterize microorganisms from diabetic and non-diabetic patients and to check the antimicrobial susceptibility of isolatedmicroorgan isms against c. sinensis and p. guajava. methodology experimental study of one year and six month duration from may 2016 to may 2018 conducted in microbiology laboratory university of lahore, pakistan. convenient sampling was done by collecting the urine sample at random from 250 persons in the pattoki community. all the urine samples from diabetic and non-diabetics were cultured separately. the first growth of microorganisms was on nutrient agar. the isolates were identified microscopically (gram staining, shape) and macroscopically (size, shape, margin, texture and surface characteristics). further identification was carried out by the use of a antimicrobial susceptibility on microorganism of diabetic and non-diabetic population j aziz fatm. med den college january – june 2023, vol,5. no.1 5 selective agar medium. media used for different organisms is given below: for confirmation of e.coli, klebsiella pneumonia, staphylococcus aureus and candida albicans, various biochemical tests were done like hemolytic activity, tsi (triple sugar iron) agar test, sugar fermentation test, indole production test, methyl red (mr) and voges-proskauer (vp) test. ripe fruits of c. sinensis and p. guajava that were free from insect infestation and other kinds of damage were collected from the local market of lahore. while other plant parts of both plants (leaves, stem bark, roots) were collected from the local gardens of pattoki. the disc diffusion method was used for carrying out the antimicrobial activity. results a urine sample of both the diabetic and non diabetic populations was taken. of these 125 were found diabetic and a further 105 were positive for urinary tract bacteria. table ii: distribution of positive urine cultures among samples. number positive urine cultures as b uti diabetic 125 75 46 29 non-diabetic 125 30 12 18 total number of samples 250 105 58 47 key: asb=asymptomatic bacteriuria uti=urinary tract infection there was a total of 105 samples that were found to have positive urine cultures. among these positive urine culture samples, 75 were diabetics and 30 were non-diabetics. the bacterial isolate most commonly found among diabetics was e. coli followed by the presence of s. aureus, k. pneumonia, p. aeruginosa, p. vulgaris respectively mic of different parts of plant extracts against isolated bacteria from diabetics showed that the highest sensitivity was found against peel, leaves and seed extracts of c. sinensis and p. guajava while the least sensitivity was shown against the stem and root extracts of these plants. the abilities of the extracts were also affected by increasing concentrations; for leaf extracts, increasing concentration (i.e., 2.5mg and 5mg) was directly proportional to the diameter of the zones of inhibition table iv: mic (mm) of different parts of plant extracts against isolated bacteria from diabetics plant species/ solvent escherich ia coli staphyloc occus aureus proteus vulgaris klebsiella pneumoniae pseudom onas aeruginos a citrus sinensis (sweet orange) leaves/ethanol 15 12 7 11 7 leaves/p. ether 11 11 5 10 5 stem/ethanol 0 0 0 0 0 stem/ p. ether 0 0 0 0 0 roots/ethanol 0 0 0 0 0 roots/ p. ether 0 0 0 0 0 peel /ethanol 20 17 10 13 15 peel/ p. ether 18 15 10 9 10 psidium guajava (guava) leaves/ethanol 25 29 12 18 15 leaves/ p. ether 21 26 10 15 13 stem/ethanol 7 7 0 10 0 stem/ p. ether 5 6 0 7 0 roots/ethanol 0 12 0 10 0 roots/ p. ether 0 10 0 9 0 seed /ethanol 10 14 7 13 10 seed / p. ether 9 12 6 10 9 table iii: isolates obtained from diabetics and non-diabetics sr. no organism diabetics positive cases non-diabetic positive cases 1 escherichia coli 41 12 2 staphylococcus aureus 19 7 3 klebsiella pneumoniae 9 5 4 pseudomonas aeruginosa 5 6 5 proteus vulgaris 1 0 table i: media used for different organism agar media organism cystine-lactose-electrolyte deficient agar (cled) pseudomonas sp. simmons citrate agar with 1% inositol (scai) klebsiella sp. mannitol salt agar (msa) staphylococcus sp. eosin methylene blue (emb) e. coli macconkey staphylococcus sp. and e. coli blood agar proteus sp. syeda atika batool et al j aziz fatm. med den college january – june 2023, vol,5. no.1 6 figure i: antibacterial sensitivity of p. guajava leaves extract against isolates a) escherichia coli b) pseudomonas aeruginosa c) klebsiella pneumoniae d) staphylococcus aureus discussion in this study, out of the 125 diabetic and non diabetic patients 60% prevalence of bacteriuria was found while in 125 non-diabetics it was 24%. according to one study, the overall incidence of uti in diabetic participants was significantly higher than in non-diabetic participants. (13.67% vs 6.40%; p=0.004). 21 another study found that 35/256 (13.67%) diabetic patients had culture positive utis compared to 18/250 (7.2%) non diabetic patients. diabetes increased the risk of uti by two-fold (p = 0.01; odds ratio [or]: 2.04; confidence interval [ci]: 1.12, 3.71). 22 these findings are consistent with the current study. these increased cases of uti in diabetics as compared to non-diabetics are because most of the early cases of diabetes and associated utis remain undiagnosed. many studies reported an even higher percentage of isolated e. coli in relation to gender of patients with uti, 96 (60.0%) were females and 64 (40%) were males. 23 urinary tract infections are mainly caused by gram negative bacteria which account for 80– 85% and the leading causative organisms are escherichia coli (e. coli) (75.5–87% of uti cases) 23 . also in this current study, e. coli was the most prevalent infection-causing agent s.aureus was the second most common culprit of uti followed by k. pneumoniae, p. aeruginosa respectively and p. vulgaris being the least common microbe isolated. other than e. coli some less prevalent pathogens were found such as klebsiella oxytoca (2.5%, each) klebsiella pneumoniae (16.3%), pseudomonas aeruginosa (5.6%) and proteus vulgaris (1.3%). similar pathogens observed in various studies. 23 the studies identified e. coli (80%) as the most associated uropathogen with utis. 24 the pattern of antimicrobial susceptibility of these uropathogens changed with the pathogen and plant part used. e. coli showed similar rates of resistance to roots and stems of guava and sweet orange plant parts. other uropathogens also showed similar resistance patterns. however, leaf extracts from both plants, as well as guava seed extract and sweet orange peel extract, were found to be the most resistant to these bacterial isolates. guava leaf ethanolic extracts demonstrated significantly high resistance to all isolates. 6. peel of citrus fruits was reported by many researchers for its antimicrobial activities 25 but there are only a few studies that focused on the antimicrobial activity of other parts of citrus such as leaves, stems and a few about roots. the current study used ethanolic extract and petroleum ether extracts from citrus leaves, stems, peel, and roots to study their antimicrobial activity. in the present study, mics of a few citrus and guava extracts against all uti pathogens (s. aureus, e. coli, proteus vulgaris, klebsiella pneumoniae, pseudomonas aeruginosa) were determined for antimicrobial activities. among them, the most effective agent was p. guajava leaf and the c. sinensis peel against all five pathogens and had potent antimicrobial activity. citrus root and stem extracts showed no antimicrobial activity against the selected bacterial pathogens. the same results were obsereved in a study by sholeh et al, where roots and stem of citrus showed no antimicrobial activity against any of the microbe isolated. 9 in this study p. guajava bark and roots extract showed no activity against all five bacterial isolates at any of the concentrations of the extract used, which may either be due to unsuccessful extraction from the bark or that the bacteria are resistant to p. guajava bark extract. the difference in activities among the different parts of the same plant is due to variations in the phytochemicals present in different plant parts. increasing concentrations of the extracts also affect their abilities; as for leaf extracts increasing concentration (i.e, 2.5mg and 5mg) was https://www.sciencedirect.com/topics/medicine-and-dentistry/gram-negative-bacteria https://www.sciencedirect.com/topics/medicine-and-dentistry/klebsiella-oxytoca https://www.sciencedirect.com/topics/medicine-and-dentistry/klebsiella-oxytoca antimicrobial susceptibility on microorganism of diabetic and non-diabetic population j aziz fatm. med den college january – june 2023, vol,5. no.1 7 directly proportional to the diameter of the zones of inhibition. overall results of our results shows that guava leaves have maximum potential against bacteria as the results show that all the isolates i.e, e. coli, staph. aureus, klebsiella pneumoniae, pseudomoa nas aeroginosa and proteus vulgaris from both diabetic and non-diabetic population showed sensitivity against leaf extracts of psidium guajava. furthermore, the extracts in ethanol were found to be more effective rather than ether extracts. there is more need to execute more and more screening of natural products or plant parts so that further phytochemical, pharmacological and in vivo studies may open the possibilities of finding the new clinically effective antibacterial compound against other bacterial-resistant pathogens. conclusion from the results, it is concluded that leaves extract of psidium guajava and citrus sinensis peel extracts showed effective results against bacterial pathogens and could serve as a good alternate source of antibacterial agents since it is a well-known fact that day-by-day microbes are becoming resistant to common antibiotics. thus, the present study presents leaves of guava and peel of sweet orange as the drug of choice for the treatment of urinary tract infection (uti) during diabetes. further concluding that according to literature guava leaves also have an anti-diabetic effect so it could prove to be the best source of drug used for utis in diabetics that would play a dual medicinal role. recommendations for future research this research recommends the use of plant parts as antimicrobial agents for utis. diabetics’ hygiene should be improved and glycemic control should be maintained as well to reduce utis prevalence. further studies can be conducted for the isolation of microbes in diabetic patients in well-developed areas of pakistan. various different plant extract solvents can be used. other components of citrus sinensis and psidium guajava can be used to test the sensitivity against microbes. acknowledgement the authors would like to express their earnest gratefulness to all the study participants from pattoki. the authors also acknowledge the expertise of the university of lahore faculty for their valuable guidance and support. references 1. pozzilli p, leslie rd. infections and diabetes: mechanisms and prospects for prevention. diabetic medicine. 1994; 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5(5):83-90. 9. sholeh saeb s, amin m, gooybari rs, aghel n. evaluation of antibacterial activities of citrus limon, citrus reticulata, and citrus grandis against pathogenic bacteria. 2016 ;4(4):1-5. 10. shagufta jasmin subi. analysis of the antibacterial and thrombolytic activity of citrus sinensis peel extracts. department of pharmacy in partial fulfillment of the requirements for the degree of bachelor of pharmacy. 2016. brac university dhaka bangladesh. 11. suja d, bupesh g, rajendiran n, mohan v, ramasamy p, muthiah ns, et al. phytochemical screening, antioxidant, antibacterial activities of citrus limon and citrus sinensis peel extracts. int j pharmacogn chinese med 2017, 1(2): 000108. 12. perez gutiérrez rm, mitchell s, solis rv. psidium guajava: a review of its traditional uses, phytochemistry and pharmacology. journal of ethnopharmacology. 2008; 117(1):1-27. 13. chu s, zhang f, wang h, et al. aqueous extract of guava (psidium guajava l.) leaf ameliorates hyperglycemia by promoting hepatic glycogen synthesis and modulating gut microbiota. front pharmacol. 2022;13:907702. 14. luo y, peng b, wei w, tian x, wu z. antioxidant and anti diabetic activities of polysaccharides from guava leaves. molecules. 2019;24(7):1343. 15. hidetoshi a and danriog, isolation of antimicrobial compounds from guava (psidium guajava l.) and their structural elucidation. bioscience, biotechnology, and biochemistry. 2002; 66(8):1727 1730/ syeda atika batool et al j aziz fatm. med den college january – june 2023, vol,5. no.1 8 date of submission: 15-11-2021 revised: 10-08-2022 accepted: 25-08-2022 16. garode am, waghode sm. antibacterial activity of psidium guajava linn (guava) leaves extracts on bacterial pathogens. 2014; 3(2):1794. 17. begum s, hassan si, siddiqui bs, shaheen f, ghayur mn, gilani ah. triterpenoids from the leaves of psidium guajava. phytochemistry. 2002 1;61(4):399-403. 18. hussain ai, anwar f, sherazi st, przybylski r. chemical composition, antioxidant and antimicrobial activities of basil (ocimum basilicum) essential oils depends on seasonal variations. food chemistry. 2008; 108(3):986-95. 19. hasija s, ibrahim g, wadia a. antimicrobial activity of citrus sinensis (orange), citrus limetta (sweet lime) and citrus limon (lemon) peel oil on selected food borne pathogens. ijcser. 2015;3(3):35-39. 20. shetty sb, mahin-syed-ismail p, varghese s, et al. antimicrobial effects of citrus sinensis peel extracts against dental caries bacteria: an in vitro study. j clin exp dent. 2016;8(1):e71-e77. 21. ramrakhia s, raja k, dev k, kumar a, kumar v, kumar b. comparison of incidence of urinary tract infection in diabetic vs non-diabetic and associated pathogens. cureus. 2020;12(9):e10500. 22. kumar r, kumar r, perswani p, taimur m, shah a, shaukat f. clinical and microbiological profile of urinary tract infections in diabetic versus non-diabetic individuals. cureus. 2019;11(8):e5464. 23. mohammed ma, alnour tm, shakurfo om, aburass mm. prevalence and antimicrobial resistance pattern of bacterial strains isolated from patients with urinary tract infection in messalata central hospital, libya. asian pac j trop med. 2016 aug;9(8):771-6. doi: 10.1016/j.apjtm.2016.06.011. 24. 24. ronald a. the etiology of urinary tract infection: traditional and emerging pathogens. am j med. 2002 ;113 suppl 1a:14s 19s. doi: 10.1016/s0002-9343(02)01055-0 25. 25. swamy mk, akhtar ms, sinniah ur. antimicrobial properties of plant essential oils against human pathogens and their mode of action: an updated review. evid based complement alternat med. 2016:3012462.doi:10.1155/2016/30 12462. author’s contribution syeda aatika batool conceived idea, study designed, data collection, manuscript farheen ansari study design, critically revised all intellectual contents and approved the final version sidra gondal study design, data collection, revise and approve the final version mahreen muhmood study design, data analysis and interpretation of results, approved the final version kainat asmat study design, data collection, revise and approve the final version all the authors are accountable for validity of data. j aziz fatm med den college jan-june 2020; vol.2, no 1 22 original article impact of shisha and cigarette smoking on lung functions in young adults muhammad sarim mumtaz, qamar javaid pansota, muhammad muneeb majeed, mahnoor mujeeb, umar abdur rehman, mohtisum rana abstract objective: to determine the impact of shisha and cigarette smoking on lungs functions and compare the pulmonary function test parameters between shisha, cigarette smokers and non-smokers. methodology: this cross-sectional study was conducted at aziz fatima medical and dental college faisalabad from january to september 2018. ethical approval was taken from the institutional ethical committee. this study consisted of 100 male college students of age 18 to 25 years. participants were enrolled on voluntary basis. prior to study, students of faisalabad based colleges were invited for study. a detailed interview of subjects was taken. subjects were questioned regarding the smoking habits using pre designed proforma. subjects who currently smoked cigarettes were classified as cigarette smokers. subjects using shisha were categorized as shisha smokers. a third category was formed which included subjects using both shisha and cigarettes, subjects without any type of smoking were non-smokers anthropometric measurements including height and weight were taken and bmi was calculated by formula weight in kg/ height in m 2. pulmonary function tests including forced vital capacity (fvc), forced expiratory volume in first second (fev1) and fev1/fvc were performed by digital spirometer. data was analyzed by spss22. values of fvc, fev1 and fev1/fvc were presented as mean ± sd and compared by anova. p value ≤ 0.05 was considered as statistically significant. results: study comprised 100 participants of mean age 20.71±1.87 years. out of the total study participants 16(16%) were cigarette smokers, 11(10.3%) were shisha smokers, 22(20.7%) were users of both cigarettes as well as shisha and 51(48,1%) were non-smokers. all three parameters of lung functions including fvc (p value = 0.005), fev1 (p value = 0.046) and fev1/fvc (p value = 0.023) were lower in cigarette smokers and significantly different from non-smokers. all three lung parameters of shisha smokers were also lower than non-smokers but statistical difference was found only in fvc values (p value = 0.000). fev1 (2.73 versus 1.5, p value= 0.66) and fev1/fvc (63 versus 50.5, p value= 0.449) was higher in shisha smokers as compared to cigarette smokers but the difference was statistically not significant. fvc value of shisha smokers was lower than cigarette smokers (2.42 versus 2.89) but no significant difference was noted (p value =0.59). conclusion: lung function parameters fvc, fev1 and fev1/fvc, were reduced in cigarette and shisha smokers as compared to non-smokers. shisha and cigarette both adversely affect lung functions, however shisha is less harmful than cigarette smoking. keywords: pulmonary function test, shisha smokers, forced vital capacity, forced expiratory volume in first second. introduction the trend of smoking in youth has become a common part of our modern society. according to world health organization (who) south east asian countries have ____________________________________________________________ dr. muhammad sarim mumtaz, mbbs dr. qamar javaid pansota, mbbs dr. muhammad muneeb majeed, mbbs dr. mahnoor mujeeb, mbbs dr. umar abdur rehman, mbbs dr. mohtisum rana, mbbs 1-6 house officer department of medicine aziz fatimah hospital fsd correspondence: dr. muhammad sarim mumtaz email: sarimawan6009@gmail.com the highest rates of tobacco smoking.1 prevalence of 47% in both genders of age 15 years and above have been reported by (who). 1 the high prevalence of smoking in form of cigarettes, cigars and flavored shisha among teens and college students has been well documented in the literature. 2 the trend of shisha smoking is continuously increasing not only in the college but also in the school going students. although men use it more frequently but now a days it is also gaining popularity in young females. shisha smoking is commonly associated with middle east, but its use is now increasing globally. 3 in pakistan, prevalence of shisha smoking in young adults is 19 33%. 3,6 muhammad sarim mumtaz et al. j aziz fatm med den college jan-june 2020; vol.2, no 1 23 shisha is also known as narghile, hookah, hubble bubble and water pipe in different societies and countries. it is a way of smoking tobacco in which vapor passes through water before inhalation. 4 tobacco smoking using shisha is emerging as a “virulent strain” in the tobacco epidemic. it affects the quality of life by having marked health problems. additionally, mouthpiece of shisha is often shared between smokers that can be a source of spread of communicable diseases such as tuberculosis. 3 young generation who is the future of the nation are unaware of the hazards of smoking, especially shisha. they have this misconception that shisha is only flavored liquid which does not affect their health, 4 thus inclining more towards shisha smoking. 2 shisha smokers believe that the water filter system in the shisha pipe filters out tobacco-specific carcinogens and is considerably less injurious than smoking cigarettes. however, they are unaware of the fact that shisha smoke has a huge amount of toxic ultrafine particles carrying similar health risks as smoking cigarette. 2,5 shisha contains harmful chemicals such as; nicotine, arsenic, methane, butane, cadmium, carbon monoxide, formaldehyde and hydrogen cyanide. 7 previous studies show that the smoke from shisha contains more nicotine as compared to that of cigarettes i.e. 2 to 4%, versus 1 to 3% respectively. shisha smoke also contains three times higher carbon monoxide levels than cigarette smoke. 8 presence of carcinogens and tumor promoters makes it a leading cause of morbidity and mortality globally. 3,6 shisha liquid comes in fruit flavored tobacco such as plum, mango, apple, coconut, menthol, strawberry etc making shisha more aromatic and thus attractive as compared to cigarettes. 7 extremely addictive nature of nicotine in cigarettes makes smoking cessation extremely difficult. shisha smoking sessions usually last for 30–90 minutes, thus shisha smokers are exposed to smoke for a longer period of time than cigarette smokers. 9 the shisha smoker inhale approximately 0.15–1 l of smoke by taking 50–200 puffs in one session. 7 additionally, the humid and cool nature of shisha smoke makes it more pleasant then dry cigarette smoke thus promoting deeper inhalation of high volume smoke causing potentially increase harmful effects on lungs. 9 fev1 and fvc are the best spirometric parameters to assess the lung functions. strong evidences are available showing reduction in lung function test leading to subsequently lethal respiratory problems including cancer. 7 previous smoking-related studies have generally been focused on traditional cigarettes, while a few researches exist on shisha smoking. most of the literature searched, addressed the adverse effects of cigarette smoking on lung functions, while failing to address the impact of shisha on lung function. similarly, researches are available showing comparison of pulmonary function test parameters (pfts) among cigarette smokers or shisha smokers with nonsmokers but data concerning comparison of pfts among shisha and cigarette smokers is deficient and impact of shisha on lung functions is still hypothesized. this study was designed to determine the impact of shisha and cigarette smoking on lung functions and compare the pfts between shisha, cigarette smokers and nonsmokers. methodology this cross-sectional study was conducted at aziz fatima medical and dental college faisalabad from january to september 2018. ethical approval was taken from the institutional ethical committee (ec/2018/01). this study consisted of 100 male college students of age 18 to 25 years. participants were enrolled on a voluntary basis. prior to study students of faisalabad based colleges were invited for study. a detailed interview of subjects was taken. subjects were questioned regarding the smoking habits such as cigarette, shisha and other tobacco product consumption, age they started smoking, the average duration of smoking, and the average number of cigarettes smoked per day. history of respiratory symptoms including cough, sputum and wheeze were also inquired. all the relevant information was recorded on a pre-designed questionnaire. female subjects were excluded. subjects who used to smoke but had since stopped were excluded from study. additionally, subjects with history of chronic obstructive pulmonary diseases, bronchial asthma, malignancy, chronic history of cough, sputum, breathlessness or chest tightness, abnormal chest wall, history of hemoptysis, drug addiction, cardiovascular disease, history of chest surgery or with history of neuromuscular disorder affecting the respiratory muscle were excluded. initially, 150 subjects were interviewed, clinical history and examination were conducted. finally, 100 healthy volunteers were selected. subjects who currently smoked cigarettes were classified as cigarette smokers. subjects using shisha were categorized as shisha smokers. a third category was formed which included subjects using both shisha and cigarette. subjects with no history of any type of smoking were classified as non-smokers. prior to enrolment informed consent was taken. anthropometric measurements including height and weight were taken by standard protocols and bmi was calculated by formula weight in kg/ height in m 2 . shisha smoking & lung function tests j aziz fatm med den college jan-june 2020; vol.2, no 1 24 lungfunctions were assessed by forced expiratory volume in the 1st second (fev1), forced vital capacity (fvc) and fev1/fvc. pulmonary function tests (pfts) were performed by digital spirometer based on the guidelines recommended by the american thoracic society (ats) and the european respiratory society (ers). 8 the tests were performed on the subjects in standing position, wearing nose clips. subjects were asked to perform breathing through a disposable mouthpiece to record normal tidal breathing for 1 to 2 minutes. at the end of a normal tidal expiration, subjects were asked to inhale as deeply as possible and then exhale as deeply as possible to get all the air out of the lungs. three maneuvers for fev1 and fvc were performed to minimize the errors. highest values were recorded for the data analysis. statistical analysis: data was analyzed using spss version 22. the demographic data was evaluated by descriptive statistics. continuous variables like age, height, weight, bmi, fev1 and fvc, were expressed as mean ± standard deviation (sd). categorical variables were presented in percentages and frequencies (cigarette, shisha and nonsmokers). means of parameters between the groups were compared by anova followed by the post hoc tukey test for multiple comparisons. p value ≤ 0.05 was considered as statistically significant. results the study consisted of 100 participants of mean age 20.71±1.87 years. frequencies and percentages of smokers and nonsmokers are presented in figure 1. figure 1: distribution of smokers and nonsmokers demographic characteristics of study population are given in table1. table 1: demographic characteristics of study population demographic variables mean standard deviation age (years) 20.71 1.87 height (meters) 1.17 1.75 weight in (kilogram) 77.26 17.87 body mass index (bmi) 25.3 7.1 the results given in the table 2 shows that the shisha smokers have lowest fvc values followed by cigarette smokers as compared to the subjects using both cigarettes and shisha and also from non-smokers. significant difference was noted in mean fvc values of smokers and nonsmokers (p value=0.001). table 1: comparisons of pulmonary function test among shisha, cigarettes smokers and non-smokers n= (100) pulmonary function test (pft) smokers nonsmokers (n=51) p values cigarette (n=16) shisha (n=11) users of both (n= 22) mean ± standard deviation fvc (l) 2.89 ± 1.04 2.42 ± 1.07 4.2± 0.98 4.50 ± 0.22 0.001* fev1 (l) 1.50 ± 0.70 2.73 ± 0.97 2.28 ± 0.72 4.75± 11.8 0.046* fev1/fvc (%) 50.5 ± 16.7 63 ± 28.2 63 ± 22.2 69.67± 25.4 0.040* forced vital capacity (fvc), forced expiratory volume in one second (fev1), differences were considered statistically significant at p ≤0.05. multiple comparison by post hoc tukey's test indicates that fvc of the shisha smokers are significantly different from the users of both cigarettes and shisha (p value = 0.002) and non-smokers (p value = 0.000). however, fvc values of shisha and cigarette smokers were not significantly different (p value = 0.59). similarly, fvc of cigarette smokers is 16(16%) 11(10.3%) 22(20.7%) 51(48.1%) cigarette smokers shisha smokers shisha &cigarette smokers nonsmokers muhammad sarim mumtaz et al. j aziz fatm med den college jan-june 2020; vol.2, no 1 25 significantly different from those using both cigarettes and shisha (p value = 0.025) and from non-smokers (p value =0.005). no significant difference in fvc values was observed between nonsmokers and subjects using both shisha and cigarettes (p value=0.73). fev1 was significantly lower in cigarette smokers as compared to the other study groups. multiple comparison of fev1 among the study groups shows that mean fev1 of cigarette smokers is significantly different from those of non-smokers (p value = 0.046) (table2). no significant reduction in fev1 of shisha users was observed. fev1 of shisha smokers, was not statistically different from nonsmokers (p value = 0.89) and users of both shisha and cigarette (p value = 0.99), fev1 of shisha users was higher than cigarette smokers but difference was statistically not significant (p value =0.66).fev1/fvc is also lowest in cigarette smokers. significant difference in mean values of fev1/fvc was noted between smokers and non-smokers (p value =0.040) (table1).multiple comparisons shows significant difference in mean fev1/fvc among cigarette smokers and non-smokers (p value=0.023). although fev1/fvc of shisha smokers were higher than those of cigarette smokers (p value= 0.449) and lower than nonsmokers but the differences was not statistically significant. (p value = 0.87). discussion shisha and cigarette smoking are major health challenges in pakistan. its high prevalence among the youngsters is alarming. this is a matter of immense public health importance as it is a leading cause of cerebrovascular accidents, chronic diseases including atherosclerosis and hypertension. smoking is also a leading risk for oral, pharyngeal, laryngeal and lung carcinoma etc. 6 tobacco smoking is a major cause of decline in lung functions leading to chronic obstructive pulmonary disease (copd) and its related morbidities and mortalities due to inhaling this poisonous chemical. 10 copd is the fourth leading cause of death in the world. 8 evidence are available showing greater annual rates of decline in forced expiratory volume in 1 st second (fev1) and greater prevalence of copd in smokers in contrast to nonsmokers. 7 current study was conducted to evaluate the impact of shisha and cigarette smoking on pulmonary functions of the young adults of 22 to 25 years. pfts including fvc, fev1 and fev1/fvc are the best parameters for assessing pulmonary function. 8 the reduction in parameters of pulmonary function test (pft) reflects the deterioration of pulmonary function prior to clinical symptoms and it results can be used to recognize subjects at risk of pulmonary diseases. 11 in the present study, fvc was significantly lower in cigarette smokers as compared to nonsmokers and subjects using both shisha and cigarettes. however, fvc of cigarette smokers was not significantly different from those of shisha smokers. significant higher reduction was also noted in fev1 and fev1/ fvc. these changes in the pattern of pfts reflect copd in cigarette smokers. the reduction in fvc of the smoker may be due to reduction in strength of the respiratory muscles. previous literature shows that cigarette smoking affects the respiratory muscles through the influence of free radicals on the vascular system causing reduction in respiratory muscle blood supply which adversely impacts respiratory function. 11 our results concerning fvc in cigarette smokers are in line with the study conducted by tantisuwat et al in thailand reporting reduced fvc levels. however concerning fev1, this study reported contradictory results and did not find significant difference in fev1 among cigarette smokers and nonsmokers. 11 another study conducted in karachi pakistan states, decline in, fvc, fev1 and fev1/fvc in young smokers of age 19-25 years of age compared to the nonsmokers of same age group. 12 like the cigarette smokers, fvc of the shisha smokers was significantly lower than those of nonsmokers. these results suggest that deep inhalation of shisha smoke due to its humid and cold characteristics affect the lung capacity of shisha smokers. fev1 and fev1/ fvc of shisha smokers were higher than those of cigarette smokers and lower than nonsmokers. although reduction in these parameters were not statistically significant difference was not found. the results of previous turkish study is in agreement with current results showing a smaller impact of shisha smoke on lung function as compared to cigarette smoke. 13 boskabady et al reported reduction in most of pfts values except fev1 in shisha smokers than nonsmokers and normal inspiration in cigarette smokers. 8 contradictory to our results, raad et al found significant reduction in all three parameters fev1, fvc and lower fev1/ fvc in shisha smokers. 14 a saudi study conducted for the evaluation of lung functions of young saudi shisha smokers also reported reduction in fev1, fev1/ fvc in shisha smokers than in the control group. 7 in subjects using both cigarette and shisha, all parameters of pulmonary function test including forced vital capacity (fvc), forced expiratory volume in one second (fev1), fev1/ fvc are similar to nonsmokers. fvc, fev1 values are significantly higher than subjects that use only cigarettes or shisha smoke. fev1 / fvc are shisha smoking & lung function tests j aziz fatm med den college jan-june 2020; vol.2, no 1 26 also higher but the difference was not statistically significant. possible reasons for pfts in these subjects might be because of the fact that they use both cigarettes and shisha; hence there are a lesser number of cigarettes which is more harmful than shisha. this is justified by previous research documenting the significant negative relation of pft values with total amount of smoking. 8 in addition, other possible cause might be difference in mode of inhalation of cigarette smoke as suggested by boskabady et al. who stated that cigarette smokers, inhale smokes, during quiet breathing. thus, they have smaller reduction in pulmonary function, as compared to the deep inspiration of shisha smoke leading to a significant decrease in lung function. 8 the findings of this study suggest that the lung function is adversely affected by shisha smoke. however, it is less injurious than that of cigarette smoke may be due to the filtration of toxic components of smoke by water pipe. in contrast to our result previous study reported that shisha and deep inspiration cigarette smoking have similar adverse impact on lung function. 8 similarly, meo et al also found a significant worsening in lung function parameters and the pattern of pulmonary function impairment was copd in shisha smokers. this finding of meo et al contradicts current results that shisha smoking is less injurious than cigarette. 7 public awareness programs in schools, colleges and universities should be arranged to raise awareness and impart health education about the hazardous effects of shisha smoking. limitations: in the current study only fvc, fev1 and fev1/fvc was evaluated. in addition to these, other parameters of pfts like peak expiratory flow (pef), maximal mid‐expiratory flow (mmef) and maximal expiratory flow (mef) should have been examined to determine the impact of shisha on lung function. in addition to pfts, respiratory symptoms such as cough, wheeze, chest tightness and production of sputum should be investigated in shisha smokers on a broader scale. conclusion lung function parameters fvc fev1, fev1/fvc, were reduced in cigarette and shisha smokers as compared to non-smokers. shisha and cigarette both adversely affect lung functions, however shisha is less harmful than cigarette smoking. funding disclosure: none. conflicts of interest: none. references 1. who global report on trends in prevalence of tobacco use 2000-2025, third edition geneva: world health organiza tion; 2019 file:///c:/users/hp/downloads/9789240000032eng.pdf. 2. aanyu c, kadobera d, apolot rr, kisakye an, nsubuga p, bazeyo w, et al. prevalence, knowledge and practices of shisha smoking among youth in kampala city, uganda. pan afr med j.2019;32:61.doi:10.11604/pamj.2019.32.61. 15184. 3. savul s. shisha use and trends in pakistan: a narrative review. jstmu. 2018; 1(1): 37-40 4. strulovici-barel y, shaykhiev r, salit j, deeb rs, krause a, kaner rj, et al. pulmonary abnormalities in young, light-use waterpipe (hookah) smokers. am j respir crit care med. 2016; 194(5):587-95.doi:10.11.64/rccm.2015 112-2470oc. 5. torrey cm, moon ka, williams da, green t, cohen je, navas-acien a, et al. waterpipe cafes in baltimore, maryland: carbon monoxide, particulate matter, and nicotine exposure. j expo sci environ epidemiol.2015;25 25(4):405-10. doi: 10.1038/jes.2014.19. 6. shah n, siddiqui s. an overview of smoking practices in pakistan. pak j med sci. 2015; 31(2):467-70.doi:10.12669/ pjms.312.6816. review. 7. meo sa, alshehri ka, alharbi bb, barayyan or, bawazir as, alanazi oa, et al. effect of shisha (waterpipe) smoking on lung functions and fractional exhaled nitric oxide (feno) among saudi young adult shisha smokers. int j environ res public health. 2014; 11(9):9638-48.doi: 10.3390/ijerph110909638 8. boskabady mh, farhang l, mahmodinia m, boskabady m, heydari gr. comparison of pulmonary function and respiratory symptoms in water pipe and cigarette smokers. respirology.2012; 17(6):950-6.doi: 10.1111/j.1440-1843. 2012.02194. 9. qasim h, alarabi ab, alzoubi kh, karim za, alshbool fz, khasawneh ft. the effects of hookah / water pipe smoking on general health and the cardiovascular system. environ health prev med. 2019; 24(1):58.doi:10.1186/s12 199-019-0811-y. review. 10. saxena s, mcbean d. an investigation into the effects of smoking on physical fitness parameters in adolescents.br j sports med 2010; 44:i30. 11. tantisuwat a, thaveeratitham p. effects of smoking on chest expansion, lung function and respiratory muscle strength of youths. j phys ther sci. 2014; 26(2): 167-70 doi: 10.1589/jpts.26.167. 12. jawed s, ejaz s, rehman r.influence of smoking on lung functions in young adults.j pak med assoc. 2012; 62(8):7 72-775. 13. kiter g,uçan es, ceylan e, kilinç o water-pipe smoking and pulmonary functions. respir med. 2000; 94 (9):8914. doi: 10.1053/rmed.2000.0859 14. raad d, gaddam s, schunemann h.j, irani j, abou jaoude p, honeine r., et al. effects of water-pipe smoking on lung function: a systematic review and metaanalysis. chest. 2011;139:764–774. doi: 10.1378/chest.100991. file:///c:/users/hp/downloads/9789240000032-eng.pdf file:///c:/users/hp/downloads/9789240000032-eng.pdf https://www.ncbi.nlm.nih.gov/pubmed/31223353 https://www.ncbi.nlm.nih.gov/pubmed/31223353 https://www.ncbi.nlm.nih.gov/pubmed/27007171 https://www.ncbi.nlm.nih.gov/pubmed/27007171 https://www.ncbi.nlm.nih.gov/pubmed/25233010 https://www.ncbi.nlm.nih.gov/pubmed/25233010 https://www.ncbi.nlm.nih.gov/pubmed/25233010 https://www.ncbi.nlm.nih.gov/pubmed/22583352 https://www.ncbi.nlm.nih.gov/pubmed/22583352 https://www.ncbi.nlm.nih.gov/pubmed/31521105 https://www.ncbi.nlm.nih.gov/pubmed/24648624 https://www.ncbi.nlm.nih.gov/pubmed/24648624 https://www.ncbi.nlm.nih.gov/pubmed/24648624 https://www.ncbi.nlm.nih.gov/pubmed/23862247 https://www.ncbi.nlm.nih.gov/pubmed/23862247 https://www.ncbi.nlm.nih.gov/pubmed/11001082 https://www.ncbi.nlm.nih.gov/pubmed/11001082 https://www.researchgate.net/deref/http%3a%2f%2fdx.doi.org%2f10.1053%2frmed.2000.0859 muhammad sarim mumtaz et al. j aziz fatm med den college jan-june 2020; vol.2, no 1 27 15. kiter g,uçan es, ceylan e, kilinç o water-pipe smoking and pulmonary functions. respir med. 2000; 94 (9):8914. doi: 10.1053/rmed.2000.0859. . 16. raad d, gaddam s., schunemann h.j, irani j, abou jaoude p, honeine r., et al.. effects of water-pipe smoking on lung function: a systematic review and metaanalysis. chest. 2011;139:764–774. doi: 10.1378/chest.100991. author’s contribution: dr. muhammad sarim mumtaz brings the ideas, study design, data collection, supervision of the research project, revise all content of manuscript and approve it. dr. qamar javaid pansota provides insight for research formulation, data collection, manuscript writing. revise and approval of final version. dr.muhammad muneeb majeed data collection, data analysis, interpretation of results critically revise and approve the final manuscript. dr. mahnoor mujeeb data collection, manuscript writing, revise and approve the final version. dr. umar abdur rehman data collection, manuscript writing, revise and approve the final version. dr. mohtisum rana data collection, manuscript writing, revise and approve the final version. all authors are equally accountable for research work and data. received: 17 feb 2019, revised received: 13 july 2019, accepted: 20 september 2019 https://www.ncbi.nlm.nih.gov/pubmed/11001082 https://www.ncbi.nlm.nih.gov/pubmed/11001082 https://www.researchgate.net/deref/http%3a%2f%2fdx.doi.org%2f10.1053%2frmed.2000.0859 j aziz fatm med den college january – june 2022; vol. 4, no. 1 31 original article fetomaternal outcome of pregnancy among women suffering from chronic hypertension nayab qasim, shabnam aijaz khowaja, erum memon, mala jitendra shahani, sumiyya khalid abstract objective: to observe the association of chronic hypertension in pregnant women on their health and fetal outcome. methodology: this cross-sectional study was carried out from september 2019 to september 2020 upon a sample of 183 consenting pregnant women (chosen via non-probability – consecutive sampling) aged 20 – 35 years admitted to the study setting via opd and emergency at gynae unit iv, liaquat university of medical & health sciences, jamshoro (lumhs). the data obtained was recorded on structured questionnaire comprising of inquiries pertaining to basic biodata, sociodemographic details, inferences obtained from history, clinical examination, and blood pressure. data obtained was analyzed using spss v. 21.0. results: the mean age of the women was 24 years ±3 sd. the mean gestational age was 38 weeks (±1 sd). a majority of the participants hailed from an urban background and most presented as booked elective cases (normal delivery more often than cesarean delivery). chronic hypertension (mean value 134/92) was present among 38.8% of the study participants. poor maternal and fetal outcome were encountered among patients with chronic hypertension. conclusion: a heavy burden of chronic hypertension was unearthed by this study which consisted of around 2/5th of whole sample. adverse maternal outcomes including postpartum hemorrhage, eclampsia & spontaneous abortion and fetal (low birth weight & neonatal deaths complications were strongly associated with chronic hypertension. keywords: chronic hypertension, feto-maternal outcome, pregnancy, hypertensive disorders, & complications. introduction hypertension during pregnancy manifests in many forms and elicits a wide array of risks to the fetal and maternal health.1,2 apart from being detrimental to fetal health, pregnancy induced hypertension (pih) takes an estimated toll of 287000 maternal deaths annually. dr. nayab qasim mbbs pgr liaquat university of medicine & health sciences, jamshoro dr. shabnam aijaz khowaja, mbbs, fcps assistant professor suleman roshan medical college and hospital tando adam dr. erum memon mbbs, fcps assistant professor jinnah medical and dental college, khi dr. mala jitendra shahani mbbs, fcps senior registrar jinnah medical and dental college, khi dr. sumiyya khalid mbbs, fcps women medical officer sindh government hospital, landhi correspondence: dr. nayab qasim email: drnayab.q@gmail.com key statistics (morbidity, mortality, and life-time risk) vary across different regions.3,4 globally, nearly onefifth of all maternal deaths may be attributed to pih, with an estimated 62000 – 77000 deaths per year, making pregnancy induced hypertension a leading cause of maternal mortality and fetal wastage globally.5,6 chronic hypertension is estimated to exist in 3-5% of pregnancies and is increasingly more commonly encountered in medical emergency. factors contri buting to these are some risk factors, such as hypertension, obesity, and older age.7,8 the condition is more common in the presence of factors such as antiphospholipid antibody syndrome, bmi >30, chronic hypertension, pre-gestational diabetes and prior preeclampsia.9,10 thus once manifested, hypertensive disorders are attributed disrupt healthy fetal growth, contribute to prematurity, and add to the already high perinatal morbidity and mortality.11 most obstetricians alert patients regarding the danger and incumbent maternal mortality associated with chronic hypertension.12 what must additionally be done however, is that information should be offered regarding the probable acute and chronic adverse outmailto:drnayab.q@gmail.com j aziz fatm med den college january – june 2022; vol. 4, no. 1 32 comes in the fetus such as prematurity and neurodevelopmental defects in the fetus of the hypertensive mothers.13 it is estimated that chronic hypertension is to blame in most cases of perinatal deaths most notably in under-developed countries and low socioeconomic population.14 according to the pakistan national health survey, “the prevalence of hypertension in pakistani adults is estimated to be 23% in urban and 18% in rural areas.15 the prevalence of hypertension in female gender is found to be 14.5%.16 the reported prevalence for chronic hypertension in pregnancy is 22%.”17 though the adverse events (during pregnancy) pertaining to the health of the mother in chronic hypertension are studied by many and a high incidence of morbidity and mortality is established, in developing countries (in particular) and around the world (in general); little is known regarding the true perinatal outcome associated with chronic hypertension among mothers. there is thus a large research gap in this aspect that merits to be fulfilled and this research is a step in this very direction since it observes the effect of chronic hypertension in pregnant women on their health and fetal outcome. this study will represent evidence for healthcare providers and policy makers in devising more appropriate interventions in improving maternal and perinatal health among pregnant women with chronic hypertension and associated disorders especially in low resource settings. moreover, the patients can be prospectively rationalized and managed early according to the findings of present study and share the results as far as chronic hypertension and fetomaternal outcome is concerned at various health care seminars. methodology this cross-sectional study was conducted from september 2019 to september 2020 at gynaecology unit iv, liaquat university of medical & health sciences, jamshoro. the study was approved by research ethics committee of liaquat university of medical & health sciences, jamshoro (letter no. lumhs/rec/-803; dated: 26/08/2019). one hundred and eightythree pregnant women were chosen via nonprobability – consecutive sampling. sample size was calculated via who open epi sample size calculator by taking the estimated prevalence of preeclampsia as 22%. the women between 20-35 years of age, primigravida as well as multigravida with gestational age varying from conception till 40 weeks, were included in the study. duration of gestation was assessed by inquiring about the history of last menstrual period (lmp) and by dating scan. all these women regardless of emergency or elective admission were included. the women with chronic renal / hepatic disease and connective tissue disorders were excluded from the study along with those having gestational hypertension who remained normotensive from conception till 20th weeks of gestation and pregnant women not giving consent or not interested to participate in the study. the informed consent form was given to the participants. study participants were included after explaining the purpose and objectives of the study to them, besides taking a written informed consent on a consent form and they were allowed to leave the study at any time. moreover, the purpose of the study, its benefits and harms were explained to the study participants. the study participants were assured that all the information received would remain anonymous and the collected data would only be used for research purpose. each participant was evaluated for maternal outcome which includes prolonged hospitalization and icu admission, fetal outcomes were low fetal weight, intrauterine growth restrictions (iugr), prematurity, respiratory distress syndrome, meconium aspiration, intrauterine death, still birth, nicu admission, and neonatal death statistical analysis: data was analyzed using microsoft excel 2016 and spss v. 21.0. qualitative data (residential status, booking status, type of delivery, maternal & fetal outcome, and complication) was expressed as number and percentage. quantitative data (age of mother, gestational week, and parity) were expressed as mean & standard deviation (x ± sd). odds ratio was calculated for the maternal and fetal outcomes among patients with and without hypertension. p value ≤ 0.05 was considered statistically significant. results the mean age of the women was 24 years ±3 sd. the mean gestational age was 38 ±1weeks). the table 1 offers interesting insight into the descriptive statistics (qualitative and quantitative). the majority of the sample is showcased to be comprised of young adults, residing in urban areas and presenting to the study setting for booked visits and eventual elective deliveries (normal delivery more often than cesarean delivery). chronic hypertension was present among 38.8% of the study participants. mean blood pressure was 134/92. poor maternal and fetal outcome were encountered among patients with chronic hypertension as shown in table 2 and 3. nayab qasim et al j aziz fatm med den college january – june 2022; vol. 4, no. 1 33 table 1: summary of the descriptive statistics (n=183) variable n (%) age (years) up to 25 87 (47.54%) 26 to 30 56 (30.6%) 31 to 35 40 (21.86%) residential status urban 95 (51.9%) rural 88 (48.1%) booking status booked 134 (73.2%) un-booked 95 (26.8%) gestational age (weeks) up to 36 38 (20.76%) 37 51 (27.87%) 38 57 (31.15%) 39 23 (12.57%) 40 14 (7.65%) parity 0 61 (33.3%) 1 to 3 75 (41%) greater than 3 47 (25.7%) delivery emergency 30 (16.4%) elective 93 (51.4%) instrumental 60 (32.2%) hypertension present 71 (38.8%) absent 112 (61.2%) the maternal outcome was normal in a vast percentage of the cases with prolonged hospitalization being reported in less than 1/4th of the cased and need for intensive care necessitated in less than 1/10th of the cases (table2). the commonest adverse fetal outcome was reported to be low birth weight, followed by nicu admissions. neither of the remaining outcomes was prevalent in more than a 1/10th of the sample (table 3). table3: fetal outcomes of pregnancy in chronic hypertension outcome n (%) intra uterine growth restriction (iugr) 07 (3.8%) prematurity respiratory distress syndrome 04 (2.2%) meconium aspiration 03 (1.6%) nicu admission 24 (13.1%) intra uterine death 15 (8.2%) still birth 04 (2.2%) low birth weight 39 (21.3%) neonatal death 05 (2.7%) the maternal complications of chronic hypertension table 4: maternal & fetal complications v/s chronic hypertension complications chronic hypertension or p values present (71) absent (112) maternal eclampsia 19 0 < 0.05* hellp syndrome 01 02 0.8 > 0.05 disseminated intravascular coagulation 0 01 0 < 0.05* pulmonary edema 05 03 2.8 > 0.05 acute respiratory distress syndrome 05 07 1.2 < 0.05* abortion 19 12 3.1 > 0.05 abruptio placentae 13 02 12.3 < 0.01* post-partum hemorrhage 23 05 10.3 < 0.01* fetal intra uterine growth restriction (iugr) 05 02 4.2 > 0.05 prematurity respiratory distress syndrome 02 02 1.6 > 0.05 meconium aspiration 01 03 0.5 > 0.05 nicu admission 14 10 2.5 > 0.05 intra uterine death 09 06 2.6 > 0.05 still birth 01 0 0 < 0.05* low birth weight 28 11 6.0 < 0.05* neonatal death 04 1 6.6 < 0.01* with the highest and significant odds of manifesting among the hypertensive individuals were eclampsia abruptio placentae which was followed by post-partum hemorrhage. among the fetal outcomes, still birth, low table 2: maternal complication & hospital stay in pregnancy due to chronic hypertension (n=183) n (%) maternal complications eclampsia 19(10.4%) hellp syndrome 03 (1.6%) disseminated intravascular coagulation 01 (0.6%) pulmonary edema 08 (4.4%) acute respiratory distress syndrome 12 (6.6%) abortion 31 (17%) abruptio placentae 15 (8.2%) post-partum hemorrhage 28(15.3%) renal dysfunction 03 (1.6%) hospital stay normal 126(68.9%) prolonged hospitalization 44(24%) intensive care unit care 13(7.1%) fetomaternal outcome of pregnancy j aziz fatm med den college january – june 2022; vol. 4, no. 1 34 birth weight and neonatal death were noted with significant odd ratio (table 4). the maternal complications of chronic hypertension with the highest and significant odds of manifesting among hypertensive individuals were eclampsia abruptio placentae, followed by post-partum hemorrhage. among the fetal outcomes, still birth, low birth weight and neonatal death were noted with significant odd ratio (table 4) discussion one in every 5 people in the country (as per pakistan national health survey), suffers from hypertension in most urban centers in pakistan. 15 pregnant women exceed this ration (22% prevalence).17 though the adverse events (during pregnancy) pertaining to the health of the mother and in chronic hypertension are studied worldwide; local literature has been scarce until this research. thus, the findings presented are largely novel. the mean age of the women was 24 ±3 sd years. this is synonymous with the norm in the local populace. the pakistan demographic health survey dictates that the mean age of marriage in the country for women is 21 years and the mean age at first child is only 22. since this research included a large proportion of primigravida women, it is expected that the age of the women may be low and match the maternal age mentioned in the pdhs survey for first child. hypertension in younger women is not commonly found and, in most instances, hypertension develops post-menopause.17,18 the mean gestational age of the women reporting to the study setting was 38 ±1 sd weeks. though, this may seem too early, but does not classify as pre-term (earlier than 37 weeks). it is well understood and much reported in literature that as compared to normal controls, women with hypertension are more likely to experience preterm deliveries and thus the result of this study is matching. it is, however, necessary to note that though the gestational period was shorter in the women in this research, it did not lead to any adverse events, and no undue risks were noted to the women. this is synonymous with the observations published by authors in the region and other developing countries where specialized healthcare centers catering to emergencies are scarce.19,20 research on local populace by shoaib un nisa et al 21 revealed that the incidence of preterm birth rises with the severity of hypertensive conditions. the prevalence is 25% among patients with pre-eclampsia and rises to 66.7% in patients with eclampsia. chronic hypertension was present among 38.8% of the study participants. as mentioned above, hypertension in certain populations in the country have been reported t o be as high as 41%. hence our finding does not seem anything out of the ordinary for the local population. nonetheless, this holds both similarities and contrast to the findings published by researchers from other parts of the world.22,23 global epidemiological surveys have reported lowest prevalence of chronic hypertension in the scandinavian countries and the highest in the united stated and western europe. though it is noteworthy that the western regions of the world are economically affluent and are a part of the developed world, the health scenarios are quite different. the difference may be due to certain confounders namely obesity, age and alcohol and smoking habits of the populace. investigating the trends however was beyond the scope of this research.24,25 while discussing maternal outcome, it is important to note that due to specialized and expert help being available at most tertiary care hospitals, complications may not always translate into a poor maternal outcome. however, it was evident that women suffering from chronic hypertension encountered poor outcomes, i.e., prolonged hospitalization (34 v.s 10) and icu admission (8 vs 5), more often. 26 research supports this finding across the globe and regardless of the country’s development status or the level of expert health and help being available. the maternal outcomes were poor across the board whenever systemic diseases such as chronic hypertension step into the equation. though there is a need to stratify in this research to account for effect modifiers, published evidence suggests that even after making adjustments for confounders, the outcome is not much different and still statistically significant.27,28 fetal outcome of the study sample was classified as iugr (3.8%), prematurity rds (2.2%), meconium aspiration (1.6%), nicu admission (13.1%), iud (8.2%), still birth (2.2%), lbw (21.3%) and neonatal death (2.7%); all notably severe and merit to be avoided. it was again revealed that women suffering from chronic hypertension encountered these poor neonatal outcomes more often than their normal counterparts. low birth weight and neonatal death were highly statistically significant. shoaib un nissa et al 21 claimed the following outcomes, namely iugr (10%), rds (20%), meconium aspiration (28.5%), iud (27.3%), lbw (30%), and neonatal death (100%). on the international front, the maternal complications revolve around 9.4% and the fetal complications are reported at around 1.3%. 29 this study is among the few attempts made at studying both, the maternal and fetal outcome and in conjunction with maternal complications among women with chronic hypertension. the statistics yielded are largely novel and offer a fresh insight into the matter. the results may help serve as the basis for future research. there are, however, some limitations of the study. first, the long-term nayab qasim et al j aziz fatm med den college january – june 2022; vol. 4, no. 1 35 follow-up was not arranged. additionally, focusing solely on women without other comorbidities, a rather limited clinical picture was obtained. furthermore, there is dearth of published evidence-based literature with which this study could be compared again intensively, thus little is known regarding how this study’s results fair against data of the local and global populace. additionally, as the extent of this research was limited to just a single city, in future similar research may be carried out on a larger sample of participants reflecting on broader demographical characteristics and taking more potential correlates to further the investigation in this field. limitation: this was a single center research, based on a single center with limited follow-up time. thus, the results have a limited generalizability and applicability. additionally, the results generated are largely novel for this locality thus there is limited evidence with which it can be compared. conclusion a heavy burden of chronic hypertension was unearthed by this study which consisted of around 2/5th of the whole sample. adverse maternal (postpartum hemorrhage, eclampsia & spontaneous abortion) and fetal (low birth weight & neonatal deaths). recommendations: it is recommended that expert help must be sought from relevant experts (physicians) to manage hypertension to the best possible level during pregnancy to avoid any undue feto-maternal outcomes and to minimize the deleterious effects it casts. a rigorous oversight supported by relevant information generated from routine (relevant) lab investigations must be available to healthcare professionals to enable them to provide the best care. the right info-care must be provided to women so adherence to hypertensive 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women with pregnancy induced hypertension have a higher risk of developing essential hypertension a case control study from a tertiary care center in pakistan. j pak med assoc.2016;66(2):179-83. 17. anthony j, damasceno a, ojjii d. hypertensive disorders of pregnancy: what the physician needs to know. cardiovasc j afr.2016;27(2):104–110. doi: 10.5830/cvja-2016-051 18. ananth cv, keyes km, wapner rj. pre-eclampsia rates in the united states, 1980-2010: age-period-cohort analysis. bmj.2013: 347; 14-15. doi: doi.org/10.1136/bmj.f6564 19. mautner e, greimel e, trutnovsky g, daghofer f, egger jw, lang u. quality of life outcomes in pregnancy and postpartum complicated by hypertensive disorders, gestational diabetes, and preterm birth. j. psychosom.obstet.2009;30(4):231-237.doi: 10.3109/ 01674 8209 03254757. 20. asif mf, pervaiz z. socio-demographic determinants of unmet need for family planning among married women in pakistan. bmc public health. 2019 ;19(1):1-8. doi: 10.1186/s12889-019-7487-5 21. nisa su, shaikh aa, kumar r. maternal and fetal outcomes of pregnancy-related hypertensive disorders in a tertiary care hospital in sukkur, pakistan. cureus. 2019;11 (8).doi:10.7759/cureus.5507 22. madan j, chen m, goodman e, davis j, allan w, dammann o. maternal obesity, gestational hypertension, and preterm delivery. j. matern.-fetal neonatal med. 2010 ;23(1):82-88. doi. org/ 10.3109/14767050903258738 fetomaternal outcome of pregnancy https://doi.org/10.3109/14767058.2014.928851 https://doi.org/10.1016/j.xagr.2021.100004 https://doi.org/10.1016/s0140-6736(06)68397-9 https://doi.org/10.1111/1471-0528.12629 https://doi.org/10.1136/bmj.g2301 https://doi.org/10.1136/bmj.i1753 https://doi.org/10.1111/j.1471-0528.1969.tb15722.x https://dx.doi.org/10.5527%2fwjn.v5.i5.418 https://doi.org/10.1136/bmj.f6564 https://dx.doi.org/10.7759%2fcureus.5507 j aziz fatm med den college january – june 2022; vol. 4, no. 1 36 23. hanif a, ashraf t, pervaiz mk, guler n. prevalence and risk factors of preterm birth in pakistan. jpma. the journal of the pakistan medical association. 2020;70(4):577-582. 24. jafar th, gandhi m, jehan i, naheed a, de silva ha, shahab h et al. cobra-bps study group. determinants of uncontrolled hypertension in rural communities in south asia—bangladesh, pakistan, and sri lanka. am. j. hypertens. 2018;31(11):12051214. doi: 10.1093/ajh/hpy071 25. castillo r. prevalence and management of hypertension in southeast asia. j hypertens. 2016;34(p e4):1-4. doi:10.1097/01. hjh. 0000499881.98439.59 26. chua yt, wong wk, gollamudi sp, leo cc. hypertension trends in asia. hypertens. 2018;4(2):84-88. 27. panaitescu am, syngelaki a, prodan n, akolekar r, nicolaides kh. chronic hypertension and adverse pregnancy outcome: a cohort study. ultrasound obstet gynecol. 2017;50(2):228-35. doi: 10.1002/ uog.17493 28. iqbal qj, javed a, marri za, sabeen n. feto-maternal outcome of pregnancy complicated with preeclampsia. j. pharm. res. int. 2020; 32(22):44-48. doi: 10.9734/jpri/2020/v32i2230770 29. subki ah, algethami mr, baabdullah wm, alnefaie mn, alzanbagi ma, alsolami rm, et al . prevalence, risk factors, and fetal and maternal outcomes of hypertensive disorders of pregnancy: a retrospective study in western saudi arabia. oman medical journal. 2018; 33(5):409-513. doi: 10.5001/omj.2018.75 date of submission: 10-07-2021 revised received: 15-12-2021 accepted: 15-01-2022 authors’ contribution: dr. nayab qasim concept, literature search, data collection, analysis, first draft write-up. dr. shabnam aijaz khowaja literature search, data collection, results, second draft write up. dr. erum memon study concept and design, analysis, final review, overall supervision. dr. mala jitendra shahani data collection statistical analysis proved the manuscript. dr. sumiyya khalid concept, data analysis & approved the manuscript. all authors are equally accountable for research work and integrity nayab qasim et al https://doi.org/10.1093/ajh/hpy071 https://doi.org/10.1002/uog.17493 https://doi.org/10.1002/uog.17493 https://dx.doi.org/10.5001%2fomj.2018.75 j aziz fatm med den college july – december 2022, vol. 4. no. 2 1 original article mortality predictors in hospitalized patients with acute exacerbation of chronic obstructive pulmonary disease (aecopd) sadhna priya, nausheen saifullah, saima akhter, asha devi abstract objectives: to determine predicting factors for in-hospital outcomes in patients with acute exacerbation of chronic obstructive pulmonary disease (aecopd) methodology: a prospective cross-sectional validation study was performed in jinnah postgraduate medical center karachi, pakistan from 2019 to 2020 at the chest medicine department, a largest public tertiary care center in karachi. all the patients with other inflammatory diseases such as malignancy, arthritis, inflammatory bowel diseases, connective tissue disorders, bronchiectasis (radiologically proven or history of phlegm expectoration >30 ml/day) or history of tuberculosis were excluded. patients with a recent history of use of antibiotic treatment or systemic steroids (prednisolone equivalent to >20 mg/day) in the preceding two months on medical record were also excluded from the study. ethical approval was taken from institutional research committee. all the patients who were presented to er with acute exacerbation of copd was included in the study, aecopd was defines anthonisen criteria. data was entered into spss version 21 for statistical analysis of the data. results: total 157 study participants were included into the study with predominance of male gender (n=106, 67.5%). the average age of study participants was 65.1 ± 11.41 years. age was significantly higher among non-survivors than survivors (p=0.037). ph level at 4 hours was significantly lower in survivors (p=0.038). heart rate (p=0.026) and respiratory rate (p=0.018) were significantly higher among non-survivors at 4 hours. among nlr, plr, pco2, po2 and hco3, a higher sensitivity of 92.59% for nlr and lower specificity of 6.15% pco2 was determined. none of these parameters had area under the curve significantly higher than 0.5. multivariable logistic regression showed that age and pco2 were independently predictors of mortality. conclusion: the present study found that increasing age and pco2 were significant predictors of mortality in in patients with acute exacerbation of chronic obstructive pulmonary disease. nlr has high sensitivity and low specificity in determining the mortality keywords: chronic obstructive pulmonary disease, in hospital-outcomes, neutron lymphocyte ratio, platelet lymphocyte ratio introduction chronic obstructive pulmonary disease (copd) dr. sadhna priya, postgraduate student chest medicine jinnah postgraduate and medical center dr. nausheen saifullah associate professor, chest medicine jinnah postgraduate and medical center dr. saima akhter assistant professor, chest medicine liaquat national hospital and medical college asha devi, mbbs civil hospital karachi correspondence: dr. saima akhtar email: drsaima82@hotmail.com and its adverse outcomes are foremost health concern globally.1 it is characterized by low-grade chronic systemic inflammation with raised cytokines and biomarkers including c-reactive protein (crp), interleukin 6(il-6) and surfactant protein d (spd).2 patients with acute exacerbation of chronic obstructive pulmonary disease (aecopd) have compromised quality of life and possess high risk mortality.3 numerous biomarkers of systemic inflammation have recently been assessed to predict mortality, however excessive costs and technical factors prevent their clinical use.4 recently, researchers have been working to explore biomarkers which could be more efficient and cost effective to predict mortality. blood mailto:drsaima82@hotmail.com j aziz fatm med den college july – december 2022, vol. 4. no. 2 2 sadhna priya et al neutrophil-to-lymphocyte ratio (nlr) has been emerging valuable predictor of inflammatory conditions and is used for risk stratification of different adverse outcomes among patients with acute coronary syndrome, pancreatitis, sepsis and infectious conditions.5 this index is a rapid, easy and cost-effective method which is a calculated index derived from a routine complete blood count test in clinical practice.3 nlr has been reported to be higher in aecopd patients than in stable patients and is associated with severity of copd6,7, 8 recently few international studies have evaluated the role of platelet lymphocyte ratio (plr) in patients with copd.9,10 to the best of our knowledge no such study has been done before in our pakistani population so far. results of international studies cannot be generalized on our local population due to gene variations of different populations in patients with copd.11 aim of this study is to determine the predictors for in-patient outcome of patients with aecopd and accuracy of nlr and plr in predicting in-hospital mortality in these patients. results of our study will not only provide the local evidence but also pave the way for planning preemptive approach in such patients. methodology a prospective cross-sectional study was performed in jinnah postgraduate and medical center karachi, pakistan from 2019 to 2020 at the chest medicine department, a largest public tertiary care center in karachi, focuses on medical care, teaching, research and provides healthcare service. this study was approved by institutional review board of jpmc with letter number (2-81/2020gfnl/4290/ jpmc) and informed consent was obtained from all subjects or their closest family member accompanying each patient. all the relevant history including history of patient’s smoking habit and biomass exposure was taken. additionally, clinical information was entered on a structured performa by research team only and patient’s confidentiality was maintained strictly. a current smoker is considered as a person who has smoked in last four weeks of his admission, while ex-smoker is considered as a person who has smoked more than 100 cigarettes in their lifetime but has not smoked in the last 28 days as per cdc guidelines. biomass term was used to describe any fuel derived from crop residues, wood, crops and animal waste. previously conducted study showed that inhospital mortality rate was 11.5% among aecopd patients (ref). using 95% confidence interval and 5% precision, a sample of total 157 patients is required. sample size calculation was performed on online calculator open-epi. nonprobability consecutive sampling was done. all consecutive patients, from both genders, and older than 16 years with clinical diagnosis of aecopd, who came to emergency department or outpatient department (opd of chest medicine department jpmc were included in the study. these patients were known cases of chronic obstructive pulmonary disease. acute exacerbation was labeled when they met anthonisen criteria; increase in sputum production, increase in dyspnea or presence of purulent sputum. all the patients with other inflammatory diseases such as malignancy, arthritis, inflammatory bowel diseases, connective tissue disorders, bronchiectasis (radiologically proven or history of phlegm expectoration >30 ml/day) or history of tuberculosis were excluded. patients with a recent history of use of antibiotic treatment or systemic steroids (prednisolone equivalent to >20 mg/day) in the preceding two months on medical record were also excluded from the study. peripheral venous blood samples were obtained using ethylene ediaminetetraacetic acid (edta), containing blood collector within 24 h after the admission. as a marker of systemic inflammation, nlr was measured as absolute neutrophil count divided by absolute lymphocyte count. plr was calculated as the platelet count divided by absolute lymphocyte count. both of plr and nlr were obtained from the same automated blood samples for the study. using nlr cut-off of >4.19 [12] and plr cut-off of >235 [13] based on previous literature, sensitivity and specificity for aecopd were measured. patients who were discharged alive were considered as survivors whereas cases of in-hospital mortality were non-survivors. data was entered into spss version 21 for statistical analysis of the data. frequencies and percentages were computed for categorical variables. numerical variables were summarized as mean ± standard deviation or median with interquartile range (iqr) as appropriate. assumption of normality was tested with shapiro-wilk test. j aziz fatm med den college july – december 2022, vol. 4. no. 2 3 mortality predictors in aecopd categorical study variables were compared between survivors and non-survivors using chisquare or fisher-exact whereas all of the nonnormal numerical variables were compared through independent sample t-test or mannwhitney u test depending on the assumption of normality. performance of biomarkers to predict mortality was assessed with sensitivity, specificity, positive predictive value (ppv) and negative predictive value (npv) and by. roc analysis. pvalue ≤0.05 was considered as statistically significant. results total 157 study participants were included into the study with predominance of male gender (n=106, 67.5%). the average age of study participants was 65.1 ± 11.41 years. out of these 125 participants with smoking exposure, majority were ex-smokers (n=75, 60%) while remaining were current smokers (n=50, 40%). out of 157 admitted patients, 27(17.2%) patients died during their hospital stay. comparison of demographics and clinical variables is presented in table 1. mean age among survivor and non-survivor was 64.08 ± 10.73 and 70.04 ± 13.38 which significantly different (p=0.037). ph level at 4 hours of admission was significantly lower in survivors (p=0.038). heart rate (p=0.026) and respiratory rate (p=0.018) were significantly higher among non-survivors at 4 hours. at 24 hours, median heart rate (p=0.009) and respiratory rate (p=0.004) were significantly higher in non-survivors than survivor group. table 3 presents the diagnostic accuracy of nlr, plr, pco2, po2 and hco3. figure 1 depicts receiver operative characteristics curve to predict mortality. area under the curve for nlr, plr, pco2, po2 and hco3 was 0.617 (95% ci: 0.50 – 0.73, p=0.057), 0.55 (95% ci: 0.42 – 0.68, p=0.429), 0.40 (95% ci: 0.27 – 0.54, p=0.115), table 1: comparison of demographics among survivors and nonsurvivors (n= 157) variables survivor n=130 non-survivors n=27 p value gender male; n (%) 87 (66.9) 19 (70.4) 0.728 female; n (%) 43 (33.1) 8 (29.6) history of diabetes; n (%) 15 (11.5) 2 (7.4) 0.739 history of htn; n (%) 49 (37.7) 7 (25.9) 0.245 history of biomass; n (%) 46 (35.4) 10 (37) 0.870 history of smoking; n (%) 102 (79.1) 20 (74.1) 0.567 p value <0.05 considered significant table 2: comparison of clinical features among survivors and non-survivors variables survivor n=130 mean ±sd?? (range) median (iqr) non-survivors n=27 mean ±sd (range) median (iqr) p value baseline ph value 7.29 (7.23 7.34) 7.26 (7.19 7.34) 0.131 baseline pco2 68 (55.95 81.78) 57.40 (45.60 83) 0.418 baseline po2 60 (46 81.44) 68 (44 105) 0.378 baseline hco3 31.50 (26.90 36.25) 26.40 (23.60 34.70) 0.098 baseline so2 87 (71.15 91.05) 88 (76 93) 0.545 baseline heart rate 98 (88 102) 98 (82 110) 0.982 baseline respiratory rate 28 (24 32) 30 (24 36) 0.075 neutrophils 8500 (7800 9000) 8800 (8300 9200) 0.068 lymphocytes 1000 (600 1800) 800 (400 1400) 0.195 platelets 238500 (176750 324500) 218000 (139000 324000) 0.699 neutrophil lymphocyte ratio 7.85 (4.68 – 14.29) 11 (5.85 – 22.50) 0.057* platelet lymphocyte ratio 214 (128.13 – 448.48) 236.67 (135 – 545) 0.429 niv: non-invasive ventilation p value <0.05 considered significant 0.55 (95% ci: 0.42 – 0.68, p=0.41) and 0.34 (95% ci: 0.25 – 0.51, p=0.048) respectively. on univarite analysis, age and pco2 were associated with mortality. multivariable model was adjusted with other covariates with p<0.25 and it was found age and pco2 were independently associated with mortality even after adjusting effects of other confounding variables (table 4). nlr= neutrophil-to-lymphocyte ratio, plr= platelet-lymphocyte ratio, pco2 = partial pressure of carbon dioxide, po2 = partial pressure of oxygen, hco3= bicarbonate table 3: diagnostic accuracy of different patients’ parameters parameters sensitivity (%) specificity (%) ppv (%) npv (%) nlr (>4.19) 92.59 21.54 19.68 93.3 plr (>235) 51.85 55.38 19.44 84.71 pco2 (>44) 81.48 6.15 15.28 61.54 po2 (<70) 51.85 33.85 14 77.19 hco3 77.78 14.62 15.91 76 j aziz fatm med den college july – december 2022, vol. 4. no. 2 4 sadhna priya et al figure 1: receiver operating characteristic curve for nlr, plr, pco2, po2, hco3 to predict mortality. table 4: predictors of mortality on univariate and multivariable logistic regression variable or (95% ci) p value a or (95% ci) p value age 1.05 (1.01 1.09) *0.015 1.06 (1.01 -1.09) 0.009 gender male 1.17 (0.48 2.9) 0.728 female ref diabetic 0.61 (0.13 2.85) 0.533 hypertension 0.58 (0.23 1.47) 0.249 0.52 (0.19 -1.43) 0.207 history of biomass 1.07 (0.46 2.5) 0.870 current smoker 0.71 (0.28 1.8) 0.469 niv application 1.63 (0.35 7.56) 0.533 pco2 ≤44 3.47 (1.04 11.58) *0.043 4.80 (1.25 -18.37) *0.022 >44 ref po2 <70 0.55 (0.24 1.27) 0.163 0.46 (0.18 1.16) 0.099 ≥70 ref hco3 <24 1.67 (0.60 4.67) 0.329 ≥24 ref nlr ≤4.19 3.43 (0.76 -15.37) 0.107 3.83 (0.79 18.67) 0.096 >4.19 ref ref plr ≥235 1.34 (0.58 3.07) 0.493 <235 ref p value <0.05 considerd significant discussion acute exacerbation of chronic obstructive pulmonary disease (aecopd) is frequent cause of hospitalization of prolong duration and has associated with significant morbidity and mortality provoked by deteriorating clinical symptoms, declining lung function, and high readmission rates.14 more precise likelihood of survival and readmission in hospitalized patients with aecopd by identifying the factors and sighting a simple and reliable biomarker that can accurately assess the mortality risk during hospitalization and is of great importance for the management of aecopd patients and rational allocation of medical resources. the mortality in our study was 17.2% (n=27), while in-hospital mortality risk ranges from 4-30% during aecopd in various studies.15 similar study conducted in south india, overall mortality rate was 34.92%, and higher number probably explains small sample size of their study and also was done on patients requiring icu care. there are number of variables that have been studied in patients with aecopd to predict the inhospital mortality. 16, 17 age is one of the risk factor that is associated with increased in-hospital mortality, one such reason given that increasing age or patients aged more than 75 years were significantly associated with mortality during hospitalization, as the patients’ fev1 declines at a more accelerated rate in older copd patients than younger ones.18 our study showed increased mortality with age (70.04 ± 13.38) with p value of 0.037, similar to the one study where age was independently found to be statistically significant for in-hospital mortality in patients with aecopd[19]. in our study comorbidities were not significantly different among survivor and nonsurvivor groups, consistent with the reports by mehta et al and morasert et al and showed no correlation of smoker copd patients compared to those of women and biomass smoke-copd, although results were not statistically significant.15,18 the explanation was probably higher proportion of comorbidities with mortality, and reported increased chances of mortality with greater number of packs years.15 most of the patients in our study in nonsurvivor group were men and tobacco smoker men than women and differences j aziz fatm med den college july – december 2022, vol. 4. no. 2 5 mortality predictors in aecopd in underlying inflammation between two risk groups. similar to one study reported, the concentration of serum cytokines involved in proinflammatory and angiogenic mechanisms decreased in women with copd-bs compared to those with copd-ts explains the differences in inflammation and its outcome. 20 clinical findings include tachycardia increased respiratory rate and the severity of the acute exacerbation as per anthonisen criteria, are all independently associated with in-hospital mortality 21, 22, 23. our study showed heart rate (p=0.026) and respiratory rate (p=0.018) were significantly higher among non-survivors at 4 hours of admission. also, at 24 hours, median heart rate (p=0.009) and respiratory rate (p=0.004) were significantly higher in the non-survivors as compared to the survivor group, corresponding to the one report that showed respiratory rate on admission was significantly associated with higher risk of death.24 blood gas values have been proven to be predictive of in-hospital mortality at the time of admission, the relationship between in-hospital mortality in copd and decompensated acidosis is well established.15 acidosis was associated with shorter interval to death signifying that these patients are acutely unwell.25. contradicting to these reports ph level at 4 hours of admission was significant lower in survivors with significant p value =0.038 in our study. in stable copd, hypercapnia is a strong independent predictor of mortality.26,27 one study reported pco2 as independent predictor of mortality in patients with aecopd.19 gunen et al also showed increased mortality rate in copd hospitalized patients with higher pco2.28 similar to previous reports our study showed pco2 was independently found to be statistically significant predictors of inhospital mortality of aecopd patients. copd is associated with both heightened airway and systemic inflammation and during states of exacerbation and rouse the increase of the nlr and plr, which may be used as prognostic markers of inflammation for patients with aecopd.29 raised nlr and plr are part of cascade of heightened systemic inflammation and aecopd is associated with increase systemic inflammation therefore rise in nlr and plr can be used as prognostic markers among patients with aecopd.29 crp is a classical inflammatory maker, and has been successfully to predict prognosis of patients with aecopd.30 taylan et al reported that increased nlr is as useful as crp in the evaluation of elevated inflammation in aecopd. the nlr is useful for the early identification of potential acute exacerbations in patients with copd who have normal levels of traditional markers.31 our study showed diagnostic accuracy of nlr at threshold of >4.19 showed higher sensitivity and npv while lower specificity and ppv. for platelet-lymphocyte ratio (plr) at threshold ≥235, showed the sensitivity of 51.85% and specificity of 55.38% and diagnostic accuracy by 19.44% ppv and 84.71% npv, which is of lower predictive accuracy than with the nlr. our results are supported by recent research from different areas of world but sensitivity of nlr in our population is higher when compared to others. rahimirad etal has showed that neutrophillymphocyte ratio has 87% sensitivity and 40% specificity in prediction of in-hospital mortality in patients with acute exacerbation of copd.32 moreover, liu j, et al. has demonstrated that nlr has sensitivity of 71.4% and specificity of 74.2% in prediction of in-hospital mortality in patients with aecopd.12 yao c, et al. has showed that nlr has sensitivity of 81.08% and specificity of 69.17% while plr has sensitivity of 64.86% and specificity of 58.27% in prediction of in-hospital mortality in patients with aecopd.9 in addition, two studies supported that elevated nlr correlation with long-term mortality in patients with copd.33, 34 although the nlr and plr was found to be sensitive marker of inflammation and thus predicting mortality, but the results were not found to be statistically significant on both univariate and multivariable logistic regression. conclusion the present study found that increasing age and pco2 were significant predictors of mortality in in patients with acute exacerbation of chronic obstructive pulmonary disease. nlr has high sensitivity and low specificity in determining the mortality. conflict of interest: none funding source: none j aziz fatm med den college july – december 2022, vol. 4. no. 2 6 sadhna priya et al references 1. rabe kf, watz h. chronic obstructive pulmonary disease. lancet. 2017; 389 (10082):1931–40. doi: 10.1016/s01406736(17)31222 2. barnes pj. inflammatory mechanisms in patients with chronic obstructive pulmonary disease. j allergy clin immunol. 2016; 138 (1):16–27. 3. liao y, huang c, wang j, fan x. association of surfactant-associated protein d gene polymorphisms with the risk of copd: a meta -analysis. clinics (sao paulo) . 2019;74: e855.doi: 10.6061/clinics/2019/e855. 4. yonchuk jg, silverman ek, bowler rp, agusti a, lomas da, miller be, et al. circulating soluble receptor for advanced glycation end products (srage) as a biomarker of emphysema and the rage axis in the lung. am j respir crit care med. 2015;192 (7):785–92. doi/full/10.1164/rccm.201501 -0137 5. yu h, jiang l, yao l. predictive value of the neutrophil to-lymphocyte ratio and hemoglobin insystemic lupus erythematosus. exp ther med. 2018;16(2):1547 –53. doi.org/10.3892/etm.2018.6309 6. taylan m, demir m, kaya h, selimoglu-sen h, abakay o, carkanat ai, et al. alterations of the neutrophil lymphocyte ratio during the period of stable and acute exacerbation of chronic obstructive pulmonary disease patients. clin respir j. 2017;11 (3):311–317. doi/10.1111/crj.12336 7. gunay e, sarinc-ulasli s, akar o, ahsen a, gunay s, koyuncu t, et al. neutrophil -to-lymphocyte ratio in chronic obstructive pulmonary disease: a retrospective study. inflammation. 2014; 37 (2):374–380. doi: 10.1007/s10753-013-9749-1 8. lee h, um sj, kim ys, kim dk, jang as, choi hs, et al. association of the neutrophil-to-lymphocyte ratio with lung function and exacerbations in patients with chroni c obstructive pulmonary disease. plos one. 2016;11 (6):e0156511. doi: 10.1371/journal.pone.0156511 9. yao c, liu x, tang z. prognostic role of neutrophil lymphocyte ratio and platelet -lymphocyte ratio for hospital mortality in patients with aecopd. int j chr on obstruct pulmon dis. 2017;12: 2285–2290. 10. karadeniz g, aktoğu s, erer of. predictive value of platelet-to-lymphocyte ratio in exacerbation of chronic obstructive pulmonary disease. biomark med. 2016;10(7) : 701-710. doi.org/10.2217/bmm-2016-0046 11. melro h, gomes j, moura g, marques a. genetic profile and patient-reported outcomes in chronic obstructive pulmonary disease: a systematic review. plos one. 2018;21 13 (6): e0198920. doi.org/10.1371/journal.pone.0198920 12. liu j, liu j, zou y. relationship between neutrophil lymphocyte ratio and short-term prognosis in the chronic obstructive pulmonary patients with acute exacerbation. biosci rep. 2019;1 39 (5): bsr20190675. doi.org/10.1042/bsr20190675 13. kumar p, law s, sriram kb. evaluation of platelet lymphocyte ratio and 90-day mortality in patients with acute exacerbation of chronic obstructive pulmonary disease. j thorac dis. 2017;9(6):1509–16. 14. rodríguez-roisin r. copd exacerbations. 5: management. thorax. 2006; 61(6):535– 544.doi:10.1136/thx.2005.041863. 15. mehta a. predictors of mortality in patients with acute exacerbation of chronic obstructive pulmonary disease requiring icu admission. the egyptian journal of chest diseases and tuberculosis. 2018 oct 1;67(4):361. 16. steer j, norman em, afolabi oa, gibson gj, bourke sc. dyspnoea severity and pneumonia as predictors of in-hospital mortality and early readmission in acute exacerbations of copd. thorax. 2012 feb 1;67(2):117-21. 17. chang cl, sullivan gd, karalus nc, mills gd, mclachlan jd, hancox rj. predicting early mortality in acute exacerbation of chronic obstructive pulmonary disease using the curb65 score. respirology. 2011 jan;16(1):146-51. 18. morasert t, jantarapootirat m, phinyo p, patumanond j. prognostic indicators for in-hospital mortality in copd with acute exacerbation in thailand: a retrospective cohort study. bmj open respiratory research. 2020 may 1;7(1):e000488 19. lahosa c, fernandez-presa l, bocigas i, miñana js, safont b, gonzalez c, servera e. predictors of mortality in copd patients after hospitalization due to an exacerbation. 20. montaño m, pérez-bautista o, velasco-torres y, gonzález-ávila g, ramos c. women with copd from biomass smoke have reduced serum levels of biomarkers of angiogenesis and cancer, with egfr predominating, compared to women with copd from smoking. chronic respiratory disease. 2021 mar 31;18:14799731211005023. 21. wildman mj, harrison da, welch ca, sanderson c. a new measure of acute physiological derangement for patients with exacerbations of obstructive airways disease: the copd and asthma physiology score. respir 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o, et al. relative survival analysis of 252 patients with copd receiving long -term oxygen therapy. chest 1998; 113:1580-7. 27. soler-cataluna jj, sanchez-sanchez l, martinez-garcia ma, sanchez pr, salcedo e, na varro m. mid-arm muscle area is a better predictor of mortality than body mass index in copd. chest 2005; 128:2108 –15. 28. gunen h, hacievliyagil ss, kosar f, mutlu lc, gulbas g, pehlivan e, sahin i, kizkin o. factors affecting survival of hospitalised patients with copd. european respiratory journal. 2005 aug 1;26(2):234-41. 29. gan wq, man sf, senthilselvan a, sin dd. association between chronic obstructive pulmonary disease and systemic inflammation: a systematic review and a meta analysis. thorax. 2004;59 (7):574–580. : 10.doi1136/thx.2003.019588 30. leuzzi g, galeone c, taverna f, suatoni p, morelli d, pastorino u. c-reactive protein level predicts mortality in copd: a systematic review and meta-analysis. eur respir rev. 2017 26(143):160070. doi: 10.1183/16000617.00702016. 31. taylan m, demir m, kaya h, et al. alterations of the neutrophil-lymphocyte ratio during the period of stable and acute exacerbation of chronic obstructive pulmonary disease patients. clin respir j. 2017; 11 (3):311 –317. doi/10.1111/crj.12336. https://doi.org/10.1371/journal.pone.0198920 j aziz fatm med den college july – december 2022, vol. 4. no. 2 7 mortality predictors in aecopd 32. rahimirad s, ghaffary mr, rahimirad mh, rashidi f. association between admission neutrophil to lymphocyte ratio and outcomes in patients with acute exacerbation of chronic obstructive pulmonary disease. tuberk toraks. 2017;65(1):25-3. 33. sørensen ak, holmgaard db, myg ind lh, johansen j, pedersen c. neutrophil-to-lymphocyte ratio, calprotectin and ykl-40 in patients with chronic obstructive pulmonary 34. xiong w, xu m, zhao y, wu x, pudasaini b, liu jm. can we predict the prognosis of copd with a routine blood test? int j chron obstruct pulmon dis. 2017;12:615 – 625.doi:10.2147/copd.s124041 authors’ contribution sadhna priya study design, acquisition of data and manuscript writing. revised and approved the articles. nausheen saifullah study design, acquisition of data and manuscript writing. revised and approved the articles. saima akhter study design, data analysis and interpretation and write up of results. revising manuscript critically for important intellectual content. asha devi study design, acquisition of data, data analysis and interpretation, revised and approve the manuscript. all authors are equally accountable for accuracy, integrity of all aspects of the research work. date of submission: 05-12-2021 revised: 20-07-2022 accepted: 23-07-2022 1 january – june 2023, vol,5. no.1 j aziz fatm. med den college editorial from separate silos to a cohesive whole: the story of integrated medical education komal atta an integrated curriculum broadly refers to collaborative methodologies of studying various disciplines together in a linked form. this has widely become the method of choice for imparting undergraduate medical education.1 in the context of pakistan, where the medical education is predominantly based on a traditional disciplinebased approach, the examples of implemented integrated curricula have been few and far between due to a number of factors namely, logistics, faculty training, faculty readiness, student to teacher ratio and infrastructure being a few prominent ones. 2 despite these challenges, the university of health sciences (uhs)recently took up the task to introduce an integrated medical curriculum in pakistan, the curriculum “2k23” has now been implemented in the 50 constituent colleges of the uhs. this effort spearheaded by the vice chancellor uhs and orchestrated via the department of medical education is a good model for understanding development of an integrated curriculum catering to a wide range of audience and keeping at par with international regulations but molding them to our local contexts as is suggested in most curriculum design studies now.3 to contextualize integration in medical education in pakistan, it is crucial to consider the unique sociocultural and economic factors that influence the delivery of healthcare services in the country. the development of the curriculum 2k23 started with an in-depth needs analysis and subsequent formation of a robust steering committee and working group consisting of a wide array of leaders as well as new entrants in medical education. the amalgamation of such teamwork produced a workable and efficient product, which gives enough flexibility to all colleges to adjust, yet maintains a certain amount of cohesiveness in the main framework. the framework follows principles of the spiral curriculum featuring three turns, the first being 1st year and 2nd year (preclinical) then third and fourth year (para clinical) and finally a dr. komal atta, assistant professor medical education the university of faisalabad, fsd pakistan. email: komal.atta@tuf.edu.pk completely clerkship oriented final year class of mbbs. in addition to this, two other spirals of clinical skills and professionalism, ethics, research and leadership skills are carried along longitudinally throughout the five years.4 all subjects are incorporated form first year onwards with the addition of holy quran and it. structuring of modules and blocks and provision to choose from an array of active learning techniques makes this curriculum fluid enough to slide up and down a few notches on the integration ladder4 (level 6 ,7 ,8 namely sharing, correlation and complementary integration) which is a welcome change given the sheer number of colleges where this is being implemented. capacity building and faculty development regarding the curriculum implementation are cornerstones to success.2 these have already been initiated by the uhs and a task force allocated to help all faculties/colleges requiring assistance. a robust feedback mechanism has been set up to evaluate the implementation and progress of this curriculum and it is recognized to be an iterative document which keeps evolving with time. this being the first tenure will prove pivotal in proceeding forward successfully if given the same berth and iteration in upcoming years also, this curriculum may help in the development of a curriculum relevant, effective, and sustainable integration model in the pakistani context. disclaimer the author is part of both the steering committee and working group of uhs curriculum 2k23 and is actively involved in its development and implementation process. acknowledgement the author would like to acknowledge vc uhs prof. dr. ahsan wahid rathore, director dme & international linkages uhs dr.col®khalid rahim and principal umdc, prof. dr aamir ali chaudhary for their endless support and openness to input regards to integration of the medical curriculum. komal atta 2 january – june 2023, vol,5. no.1 j aziz fatm. med den college references 1. wijnen-meijer, m., van den broek, s., koens, f. et al. vertical integration in medical education: the broader perspective. bmc med educ 20, 509 (2020). https://doi.org/10.1186/s12909-02002433-6 2. shaheen n, khan ra, yasmeen r, sajid mt. probing in the complexities of the integrated undergraduate medical curriculum: a qualitative exploratory study. j pak med assoc. 2022 3. sanyumay tun (2019) fulfilling a new obligation: teaching and learning of sustainable healthcare in the medical education curriculum, medical teacher,41:10,11681177, doi:10.1080/0142 159x.2019.1623870 4. harden rm. the integration ladder: a tool for curriculum planning and evaluation. med educ. 2000 jul;34(7):551-7. doi: 10.1046/j.1365-2923.2000.00697.x. pmid: 10886638. date of submission: 07-01-2023 revised: 02-02-2023 accepted: 07-02-2023 journal.cdr editorial emerging need of new medical journals medical advances will keep on putting upward pressure on the need for new medical journals (to find a space for publications). dissemination of data from clinical trials needs to be on urgent basis for the benefit of millions of people. authors themselves want to publish their work at earliest. our journal must guarantee this after a rigorous 1 peer-review unfortunately in pakistan many publication have been uncontrolled, unregulated and with erratic results. in view of above, to maintain the standard, many medical journals of pakistan have been de-recognized or downgraded recently. many doctors were contributing articles to the journals only to improve their curriculum vitae for promotions or support grant proposals. new journals i am sure must be carrying results from strictly controlled process and would be useful for medical professionals and patients alike. articles won't be meant to secure tenure and 2 further grants or by the need of pharmaceutical industry to promote their products. this positive trend has created a chance for new high quality journals recognition. hopefully new journals will come up to the standards to be of any use. in pakistan the medical education programs till now assumed that training was not needed for written medical communications. recently this subject has been taken up seriously at many levels. medical students and house officers will be encouraged to participate in research work and get their articles published. they would be provided 3 with experienced mentors with a record of good publications. another important issue getting the article published in a reputable journal is the cost. moreover cost of publishing in open-access journals bears little correlation to their 3 impact. once recognized we will try to keep our cost of publishing to the minimum. common shortcomings of the journal publications are insufficient quality of the information provided and outcome reporting bias. this can be cover by the and peer review by experts. reporting guidelines ew ways of data presentation bias can be avoided by adopting n 4,5 in electronic databases and the potential use of anonymized individual patient data. we will try to give equal 4 opportunities to ladies to serve as peer reviewers and editorial writers, in contrast to previous practices. our editors have to focus on professionalism to establish transparent and ethical working practice. medical writing encompasses a wide field of diverse forms of written communication. useful material has to be distinguished from ordinary messages. aziz fatimah medical journal must be considered a sacred space meant for intellectuals willing to share their honest research for the betterment of society. i hope and i pray that our journal will come up to the mark of highest standards at least in pakistan. references 1.pozzilli, p. fast publication, a must for a journal. diabetes metab res rev, 2018; 34(1). doi: 10.1002/dmrr.2978.34. 2.matheson a. canself-regulation deliver an ethical commercial literature? acritical reading of the "good publication practice"(gpp3) guide lines for industry-financed medical journal articles.2019; 26(2):85-107. doi: 10.1080/08989621. 3.yuen j, muquit s, whitfield pc. correlation between cost of publication and journal impact. comprehensive crosssectional study of exclusively openaccess surgical journals. j surg educ. 2019; 76(1):107-119. doi: 10.1016/j.jsurg.2018.06.029. 4.williams wa, garvey kl. the role of gender in publication in the journal of pediatrics 2015-2016: equal reviews, unequal opportunities. j pediatr. 2018; 200 :254-260.e1. doi: 10.1016/j.jpeds.2018.06.059. review 5.wieseler b. beyond journal publicationsa new format for the publication of clinical trials. z evid fortbild qual gesundhwes. 2017 feb;120:3-8. doi: 10.1016/j.zefq.2016.11.003. chief editor maj. gen (r) prof. dr. hamid shafiq hi (m) principal aziz fatimah medical and dental college,faisalabad. jafmdc jan-june 2019;vol.1, no.1 page 2 34 january – june 2023, vol,5. no.1 j aziz fatm. med den college case report rare complication of percutaneous nephrolithotomy: nephrostomy tube in renal vein and inferior vena cava muhammad akram malik, adeen akram, maryam anwar, farhan jamshed, asad ramzan abstract: percutaneous nephrolithotomy (pcnl) is considered as the gold standard treatment for renal stones > 2cm. we encountered a patient who underwent pcnl and inadvertently placement of percutaneous nephrostomy tube in the inferior vena cava through the left renal vein from the left kidney. there was profuse bleeding during the procedure (pcnl), and the procedure was abandoned by placing a nephrostomy tube. pnt was removed after 04 days in two steps without any bleeding. keywords: percutaneous nephrolithotomy, inferior vana, cava renal vein introduction fernstrom and johansson 1976 introduced percutaneous nephrolithotomy (pcnl)1. it is now considered as gold standard treatment for renal stone > 2cm. pcnl has a complication rate of 7%. 2 putting of nephrostomy tube (pnt) is a common procedure after completion of pcnl. inadvertent placement of (pnt) into the ipsilateral vein or vena cava is very rare and can cause serious complications. if pnt is not carefully managed, it can cause venous perforation, leading to severe hemorrhage, embolism, and sepsis.2-6 case report a 26-year heavy-built male underwent left pcl for staghorn renal stone at medina teaching hospital fsd, pakistan. the procedure had to be immediately terminated after dilatation and putting in amplats sheath due to profuse venous bleeding. a pnt was placed to control bleeding. the patient remained hemodynamically stable after the procedure. on the first post-operative day, x-ray muhammad akram malik, mbbs, fcps professor university medical college, faisalabad adeen akram mbbs pgr, dhq hospital, faisalabad marraym anwar, ms-1, noorda college of osteopathic medicine, provo, utah, united states of america. farhan jamshed , mbbs senior registrar, university medical college, faisalabad asad ramzan, mbbs student, shalamar medical college, lahore. correspondence muhammad akram malik akrammlk@yahoo.com kub and contrast study were performed, which showed the ptn traversing through the left renal parenchyma into the left renal vein and vena cava (fig-i). the patient was kept under observation for any untoward incidence for the next 2-3 days, under broad-spectrum antibiotic cover. on the 4th post-operative day, we retrieved the pnt under fluoroscopic control till it reached the calyceal system. the recovery period was uneventful. on the 5th post-operative day, a contrast study was done, which indicated the presence of pnt in the calyceal system and the free flow of contrast into the bladder (fig-ii). observation for any complications and discharged on the next day. the patient was scheduled for the next pcnl after 03 months. discussion inadvertent and misplacement of pnt into the renal vein and inferior vena cava (ivc) is a very rare phenomenon. pnt can enter through renal parenchyma into the renal vein and /or slip into the inferior vena cava.7 it has been reported in one case that pnt reached up to the atrium.8 there are various reasons why this rare complication may occur. misjudgment of the length of pnt or depth of the tube insertion is probably the main cause of this complication. misplacement of pnt may be catastrophic and may lead to serious complications like severe hemorrhage, systemic infections and sepsis or embolism if not managed properly. on the 5th day, pnt was removed, and the patient was kept for another day under previously mazzucchi e et al has documented two cases of misplacement of nephrostomy tubes into the renal vein and ivc during percutaneous nephrolithotomy.2 the 35 january – june 2023, vol,5. no.1 j aziz fatm. med den college muhammad akram malik nephrostomy tube was removed at 48 and 72 hrs, respectively, and the surgical team was standby for emergency open surgery in case of uncontrolled bleeding, however no bleeding was occurred. chen et al. have published three cases with misplaced nephrostomy tubes.8 tubes were placed into the venous system during pcnl. they managed these figure 1: nephrostomy tube inside the ivc figure 2: nephrostomy tubes in pelvis of kidney after removal from ivc and renal vein and contrast going into ureter and bladder patients with intravenous antibiotics and strict bed rest. tube was removed in one step in one case. in two other patients, tubes were withdrawn up to the renal pelvis in the first step. complete removal was done in the second step under close monitoring and clinically stable patients. the decision of singlestep or two-step withdrawal was based on the level of placement of the tube in the venous system. the outcome of patients in these cases was eventless. another study by kotb et al and tarhan et al. 9,10 removed the pnt by open surgery without hemorrhage. in our case, we removed the pnt in two steps. in the first step, on the 4th post-operative day, we retrieved the pnt from the renal calyceal system and on the 5th post-operative day removed the tube under strict observation in the operation theatre with the surgical team standing by. according to our experience and literature review, a misplaced pnt can be removed in the early post-operative period without any hemorrhage, but the surgical team should be ready for any emergency surgical intervention. conclusion malplacement of pnt in the venous system is very rare. it may lead to serious complications if managed improperly. pnt can be removed safely, however, team for potential surgical intervention should be ready during this removal procedure. conflict of interest: none there is no conflict of interest: none references 1. fernstro¨m i, johansson b. percutaneous pyelolithotomy. a new extraction technique. scand j urolnephrol 1976;10(3):257-259. doi: 10.1080/21681805.1976.11882084 2. mazzucchi e, mitrea, brito a, arap m, murta c, srougi m. intravenous misplacement of the nephrostomy catheter following percutaneous nephrostolithotomy: two case reports. clin sao paulo braz 2009;64:69e70. 3. mallmann cv, wolf k-j, wacker fk. retrieval of vascular foreign bodies using a self-made wiresnare.actaradiol stock swed 2008;49(10):1124-1128.doi:10.1080/028418508024 54741. 4. koseoglu k, parildar m, oran i, memis a. retrieval of intravascular foreign bodies with goose neck snare. eur j radiol2004;49(3):281-285.doi:10.1016/s0720-048x(03)00078-0. 5. shaw g, wah tm, kellett mj, choong sks. management of renal-vein perforation during a challenging percutaneous nephrolithotomy. j endourol 2005 ;19(6):722-723. doi:10.1089/ end.2005.19.722. 6. winfield hn, weyman p, clayman rv. percutaneous nephrostolithotomy: complications of premature nephrostomy 36 rare complication of pcnl january – june 2023, vol,5. no.1 j aziz fatm. med den college dias-filho ac, coaracy gav, borges w. right atrial migration of nephrostomy catheter. intbraz j urol off j brazsocurol 2005;31(5):470-471. doi:10.1590/s1677-55382005000500009. 7. tube removal. j urol 1986;136(1):77-79. doi: 10.1016/s00225347(17)44733-1. 8. chen xf, chen sq, xu ly, gong y, chen zf, zheng sb. intravenous misplacement of nephrostomy tube following percutaneous nephrolithotomy: three new cases and review of seven cases in the literature. intbraz j urol 2014; 690-696. doi: 10.1590/s1677-5538.ibju.2014.05.15 9. kotb af, elabbady a, mohamed kr, atta ma. percutaneous silicon catheter insertion into the inferior vena cava, following percutaneous nephrostomy exchange. can urol assoc j j assoc urol can 2013;7:e505e7.. 10. tarhan h, akarken i, cakmak o, can e, ilbey yo, zorlu f. misplaced nephrostomy catheter in left renal vein: a case report of an uncommon complication following percutaneous nephrolithotomy. urol j. 2014 ;11(3):1714-1716. 11. li d, xiao l, tang z, qi l, luo k, huang ll. management of intravenous migration of urologic catheter. urology 2013; 20;82(1):248-252. doi: 10.1016/j.urology.2013.03.006. 12. wang c, chen s, tang f, shen b. metachronous renal vein and artery injure after percutaneous nephrostolithotomy. bmc urol 2013;13:69. doi: 10.1186/1471-2490-13-69 13. fu w, yang z, xie z, yan h. intravenous misplacement of the nephrostomy catheter following percutaneous nephrostolithotomy: two case reports and literature review. bmc urol 201;14:17(1):43. doi: 10.1186/s12894-017-0233-3 author’s contribution muhammad akram malik & farhan jamshed reported case adeen akram , marraym anwar & asad ramzan compile all material and drafting of report all authors are equally responsible for integrity of material provided and case report date of submission: 23-04-2022 revised: 15-12-2022 accepted: 15-01-2023 july december 2019; vol. 1, no. 2 j aziz fatm med den clg 48 editorial launching of new medical journals benash altaf these days research culture is flourishing at a break neck pace. national and international higher educational authorities are also encouraging this scientific culture. for this purpose, they are providing grants and funding. in pakistan, higher education commission (hec), pakistan medical and dental council (pmdc) and college of physicians and surgeons of pakistan (cpsp) is also facilitating undergraduate and postgraduate students and making it compulsory by giving the incentive in the form of scores to qualify for their specialized training. similarly, they have fixed certain scores for research publications even for postgraduate doctors that without certain specified number of publications they would not be promoted. in this way, they have made it sure that this trend is kept on going in continuity.1 to cope with number of research articles coming from all over the state, initially fewer journals were there to bear all the load of research publication. regulatory authorities have to realize this emerging issue. so they should facilitate medical institutions to launch their journals with transparent policy with a vision that it is essential to keep pace with current era in medical field. this will also help to lessen the burden of publications over the pioneer journals. research publications are important tool for an academic career progression as it uplifts the scientific culture and give it a wind to flourish the academic foundation. consequently, realizing the need of current era, many medical institutes are launching their journal with a vision that they would try to contribute their maximum to the medical literature. on the other hand, some researchers write just to get the fame and getting the top ranked position as described by sultan pyramid.2 in order to maintain the scientific standard of these journals hec has classified them into different categories in order to rank these journals as “good category”, “very good” and “best” (w,x,y,z). these journal are not only playing a pivotal role in minimizing the rush that was once on pioneer journals but the emerging new journal also provide competitive environment to the already existing journals. ____________________________________________________________ correspondence: dr. benash altaf aziz fatimah medical & dental college, faisalabad associate editor jafmdc email: altafbenash@gmail.com to publish an acceptable standard scientific journal, hec and pmdc though have formulated certain guidelines and policies which are to be followed by new journals. this was good in aspect of maintaining and raising the literature standard thence ultimately hiking the number of citations.3 still certain policies are still not in descriptive format. in a result, some journals failed to full fill this vision and were unsuccessful in contributing the standard medical literature. pmdc should play crucial role over here by keeping check and balance on the journals. they however, derecognized, and even stop the publication of some journals. but pmdc role does not just ends here, as still some previously recognized journals are still publishing their journal whose standards are now not up to the mark. they are still continuously publishing articles with scientific limitations.4 these include biased peer review, ethical and similarity checking issues, formatting flaws that must be checked by the editorial team. most probably there aim is not more to provide the quality medical literature but are publishing article in context just to up lift the curriculum vitae of their personnel or just to launch numbers of issues for the business purpose.5 so these journals before launching their new issues must improve all shortcomings by properly following the editorial process to meet the international standards. it also requires high quality manuscript with proper peer reviewed policies and these rules should not be compromised. moreover, it is the duty of institute to realize it as a noble ethical responsibility to which an institute must consider itself to be accountable. furtherly, here implies the duty of experienced editors from all over the world to play their role for uplifting the ethical and moral values of new editors that should not be compromised at any cost.6 pmdc should also instead of derecognizing the journals must provide the author with ample of opportunities for their publications.5 hence, these authorities must encourage new journals but with proper check and balance policies as full protocol followed published journal will also help to uplift our research ranking. pmdc should describe this protocol in the form of structured policies, formatting pattern and printing quality in a black and white format that the journal must have to follow before getting it published. july december 2019; vol. 1, no. 2 j aziz fatm med den clg 49 these policies should be equally implemented on all the journals for the integrity of the standard. in this way, new institutes would not face problems in getting their journal recognized. these steps will help to encourage the marvelous writers and valued researches to bring them out in front of the world that will definitely make feel them symbol of honor and proud for the nation.7 conflicts of interest: none. references 1. mushtaq a, fatimah r, rehman a. medical students and medical research in pakistan. j pak med assoc. 2012; 62 (5):527-528. 2. meo sa. anatomy and physiology of scientific paper. saudi j bio sci.2018; 25(7):1278–1283 3. meo sa, jawed sa. pakistan’s performance in global impact factor race. pak j med sci. 2018; 34(4):777-780. 4. jawed sa. professional in medical journalism and role of hec, pm&dc. ann king edward med uni. 2016; 22(3): 164-166 5. jawaid sa. authorsthe most dangerous pressure group. pak j med sci 2014; 30 (6):1177-1179 6. kothari r, bokariya p, nongrum sm, singh r. an account on the count of mushrooming journals. int j clin exp physiol 2018; 5:54-55 7. ahmad b, husain aa, dossani k. impact factor of pakistani medical journal. j pak med assoc. 2013; 31(1):131 benash altaf https://www.annalskemu.org/journal/index.php/index j aziz fatm med den college jan-june 2020; vol.2, no 1 28 letter to the editor covid 19: what do we need to do right now ahmad hassan khan madam, on 26 th of february 2020, zafar mirza, the prime minister’s special assistant on health confirmed via a tweet first two cases of coronavirus in pakistan, first case was reported from karachi and second case was reported from islamabad, both were recently returned from iran. 1 within less than a week, cases in all provinces were confirmed. on march 11, 2020 who, declared covid-19 a pandemic and it has impacted more than 195 countries worldwide. 2 various necessary steps were taken by pakistan government to minimize the spread of the virus and more importantly making arrangements for treatment of corona patients at healthcare facilities. 3 the number of confirmed covid-19 cases in pakistan has crossed 148,921 with 56,3900 recoveries and around 2,839 deaths in the country, whereas number of confirm patients in punjab have approached to 55878 till 15 june 2020. 4 there is a dire need to sensitize masses to take necessary precautions for stopping transmission of virus as during the recent relaxation in the lock down just before eid major violations of the standard operating protocols were observed throughout the country. bed occupancy for example is almost at maximum capacity at divisional headquarters hospital sargodha. the coming few weeks are going to be extremely challenging for the doctors as they have to deal with the dilemma of counseling the raging attendants also. unless a very close eye is kept on the evolving situation there is a chance of chaos at hospitals. __________________________________________________________ correspondence: dr ahmad hassan khan, mbbs , fcps associate professor surgery sargodha medical college, university of sargodha email: docahmadhassan@hotmail.com limited research has been done and published locally so far in pakistan. there is a need to encourage health care professionals to conduct various research projects related to covid-19 as this will in turn help the health force to target the observed deficiencies found hence helping the health force to provide better care of suffering patients. conflicts of interest: none. references 1. dawn, pakistan confirm first two case of corona virus, govt says “ no need to panic”(online) updated february 26, 2020. available from url: https://www.dawn.com/news/1536792 (date of access: june 15, 2020) 2. mubeen sm, kamal s, kamal s, balkhi f. knowledge and awareness regarding spread and prevention of covid-19 among the young adults of karachi. j pak med assoc. 2020 70 (suppl 3)(5):s169-s174. doi: 10.5455/jpma.40. 3. mukhtar s. preparedness and proactive infection control measures of pakistan during covid-19 pandemic outbreak. res social adm pharm.. 2020. doi10.1016/j.sapharm.2020.04.011 4. government of pakistan. pakistan cases details. available from url:http://covid.gov.pk/stats/pakistan (date of access: june 15, 2020 mailto:docahmadhassan@hotmail.com https://www.dawn.com/news/1536792 https://www.ncbi.nlm.nih.gov/pmc/articles/pmc7151296/ https://www.ncbi.nlm.nih.gov/pmc/articles/pmc7151296/ http://covid.gov.pk/stats/pakistan%20%20(date j aziz fatm med den college july – december 2022, vol. 4. no. 2 30 original article knowledge of the human monkey pox infection among medical practitioners in punjab, pakistan romaisa khalid, sumera ehsan, ayesha khalid, khalid mahmood abstract: objective: to assess the knowledge of medical practitioners regarding the human monkey pox infection. methodology: a cross sectional study was performed between june 2022 and august 2022 among medical practitioners in punjab, pakistan especially the medical practitioners from major cities including lahore, faisalabad, multan. data was collected through an online, self-administered questionnaire. piloting was done and feedback was taken. all the registered doctors working in different areas of pakistan were included in this study. all non-registered doctors, nurses and paramedical staff were excluded from this study. ethical approval was taken from the office of the ethical review committee, faisalabad medical university, letter number: 48-erc/fmu/20212022/232. data was analyzed using spss version20.0. results: out of the 250 participants, 52(20.8%) were house officers, 78(31.2%) were medical officers,78(31.2%) were postgraduate residents and 16.8% were consultants. among 250 participants, 170(68%) were in between the ages of 23 to 33, 16.4% between 34 to 44 and 39(15.6%) were between 45 to 55 years of age. our 229(91.6%) participants were aware of the human monkey pox infectio n [hmpi] and 8.4% were not aware of hmpi. only 115(46%) participants consider hmpi similar to smallpox. majority of the respondents were aware of the predominant symptoms of the hmpi. only 116(46.4%) participants consider 2nd and 3rd generation small pox vaccines to be effective against the human monkey pox virus [hmpv]. conclusion: this study shows the knowledge of medical practitioners is relatively low. but considering the fact as being a newly emerging disease in asian countries the overall response of doctors was a bit reasonable. due to high alert by who there is an utmost need of training sessions for medical practitioners. keywords: knowledge, human monkey pox infection, medical practitioners. introduction human monkey pox is a viral zoonosis caused by the monkey pox virus (mxpv), an enveloped double stranded dna virus belonging to the genus dr. romaisa khalid mbbs faisalabad medical university. dr. sumera ehsan mbbs, mme prof. faisalabad medical college, pmc, fmc, fsd. pakistan. ayesha khalid 2nd year mbbs faisalabad medical university, fsd, pakistan dr. khalid mahmood phd senior scientist, ayub agriculture research institute, fsd, pakistan. correspondence: dr. romaisa khalid email: romaisakhalid96@gmail.com orthopoxvirus of poxviridae family.1 mpxv was first discovered during an outbreak amongst monkeys at a danish laboratory in 1958. 2 it was first identified as a human pathogen in the democratic republic of the congo (drc, formerly zaire) in 1970. 3 mpx is typically found in the tropical rain forests of the congo basin (cb) and west africa (wa), and drc continues to report most cases each year 4, mainly in children under 10 years. the first outbreak outside of africa was in united states of america in 2003.5 in may 2022 multiple cases of monkey pox were reported in several nonendemic countries.8 raising a moderate global threat for all communities.9 owing to this fact who has advised all countries to be on alert for patients presenting with rashes evolving different mailto:sumeraehsan@yahoo.co.uk j aziz fatm med den college july – december 2022, vol. 4. no. 2 31 romaisa khalid et al sequential stages.9 in the light of who’s advice, federal government in pakistan has declared high alert against monkey pox. though up till today no monkey pox case has been reported in pakistan.10 the human monkeypox virus has a mean incubation period of about 6 to 13 days leading to the human monkeypox infection that has similar clinical manifestation to the small pox infection with lymphadenopathy as a differentiating feature.5 the patient infected with hmpv presents with fever, myalgias headache, lymphadenopathy and skin lesions preferably on the face and extremities.6 the rashes evolve from maculopapular to vesicular to pustular and crust off that eventually falls, labelling a patient noninfectious. the human-to-human spread of the hmpv is via contact with the body fluids of the infected person. 16 vertical transmission can lead to congenital hmpi.17 the hmpi responds well to symptomatic management including increased hydration, antipyretics, antivirals and antibiotics for secondary bacterial infections. second and third generation small pox vaccinations have been declared effective for the control of the hmpi. so, who has recommended vaccination of all the high-risk individuals and post exposure vaccination within 4 days of 1st exposure for every exposed person. health care team forms the basic pillar in combating any epidemic. knowledge of health care workers especially the doctors constitute the basis of response of the nation towards any evolving medical emergency in the country. methodology this cross-sectional study was conducted from june 2022 to august 2022 among the medical practitioners serving in the public and private sectors in punjab, pakistan especially the medical practitioners from major cities including lahore, faisalabad, and multan. ethical approval was taken from the office of the ethical review committee, faisalabad medical university, with letter number: 48-erc/fmu/2021-2022/232. for enrollment of participant’s convenient sampling technique was used. calculated sample size was 250 participants. a self-structured questionnaire was formed using the previous literature and was validated from senior doctors. piloting was done and feedback was taken using 10 forms. data was collected through google forms by sharing links through personal contacts. all the registered doctors working in different areas of pakistan were included in this study. all non-registered doctors, nurses and paramedical staff were excluded from this study. statistical analysis: data was analyzed using spss version20.0. categorical variables are presented as percentages and frequencies. results out of the 250 participants 52(20.8%) were house officers, 78 (31.2%) were medical officers, 78(31.2%) were postgraduate residents and 42(16.8%) were consultants. our 170(68%) participants were in between the ages of 23 to 33, 42(16.4%) between 34 to 44 and 39(15.6%) were between 45 to 55 years of age. in this study 229(91.6%) were aware of hmpi and 237(94.8%) participants correctly answered it as a viral infection. whereas 191(76.4 %) participants know that hmpv is easily transmissible and out of these, only 90(36%) participants are aware of its transmission through body fluid. surprisingly, 181(72.4%) were aware of the vertical transmission of hmpv. only 131(52.4%) participants were aware of the incubation period of 6 to 13 days. only 115(46%) participants correctly consider hmpi similar to smallpox. medical practitioners were also inquired regarding the clinical presentation of hmpi and we received the results as shown in table no. 1. percentage of doctors who have answered correctly is mentioned in accordance to the professional status. only 135(54%) participants were aware of the fact that face and extremities are the favorite site of skin lesions. when questioned about the recommended management of the human monkey pox infection only 119(47.6%) doctors table 1: knowledge of physicians regarding clinical manifestation of hmpi. symptom of hmpi house officers 52 (20.8%) medical officers 78 (31%) postgraduates 78 (31.2%) consultants 42 (16.8%) headache 23 (18%) 45 (36%) 35 (28.6%) 19 (15.5%) fever and myalgia’s 42 (21%) 71 (35%) 56 (28%) 31 (15.5%) lymph adenopathy 33 (17.9%) 64 (34%) 53 (28.8%) 34 (18.4%) j aziz fatm med den college july – december 2022, vol. 4. no. 2 32 knowledge of hmp infection among medical practioners were aware of the accurate management guidelines as described in figure 1. figure. 1: knowledge regarding management of hmpi only 116(46.4%) participants correctly answered about the 2nd and 3rd generation small pox vaccines to be effective against hmpv while 69(27.6%) consider smallpox vaccination ineffective against hmpv discussion in the current study majority of the medical practitioners were working as medical officers and postgraduate residents. hence most of the participants were young doctors with 170(68%) of the participants in age group ranging from 23 to 33 years. participants were found to have relatively good knowledge regarding what is hmpi, its routes of transmission and majority of the healthcare workers were aware of the vertical transmission. we got good responses regarding the knowledge of clinical presentation of hmpi. majority of the participants were aware of the predominant features of the infection. smallpox shares common clinical manifestation as both small pox virus and human monkeypox virus belongs to the same family, and is a challenging differential diagnosis. in this study 115(46%) of the healthcare worker were aware of the similarity between hmpi to smallpox. among these two viral infections only lymphadenopathy, occurring in hmpi, is the differentiating feature and 184(73.6%) of our participants were aware of this difference. but only 113(45.2%) of our respondents were aware of the sequentially evolving rash and sites of lesions and the responses received in the domains of management, recognition of skin lesions, incubation period and vaccination showed low knowledge in all professional groups of doctors. previous crosssectional similar study carried out in indonesia in march 2020 11, also showed the same corresponding results related to the knowledge of hmpv in medical practitioners. similar results were received in a similar study in kuwait in 2022.14 however, according to the preliminary report of a recent cross-sectional study carried out in saudi arabia in 2022 15, the knowledge of medical practitioners regarding hmpi was even lower as compared to the responses we received in current study. second and third generation small pox vaccinations are effective against the hmpv. 12 according to a research article published in the proceedings of the national academy of sciences of the united states of america, thirty years after mass smallpox vaccination campaigns ceased there was a dramatic increase in the cases of the hmpi. in the current study less than half of the participants were aware of the effectiveness of small pox vaccines against hmpv. incubation period is really important in dealing with an infection and in the current study only half of the participants were aware of the incubation period of hmpv. isolation of an infected person can control the spread of hmpi and in our study only (38.8%) doctors were aware of the isolation period required for a person infected with hmpv. according to a research article published in the nature scientific journal of england in may 2022 13, the human monkeypox virus (hmpv) spreads from close contact with body fluids of infected person. that means a person with monkeypox is likely to infect his close contacts more than rest of the population. so, health-care workers will use “ring vaccination” that includes vaccination of the close contacts of infected person with monkeypox to cut off any routes of transmission. this is in accordance to the who guidelines that recommends vaccination of high-risk persons as a pre-exposure prophylaxis. in the current study 48% of the participants were aware of this current strategy of vaccination against the human monkeypox virus. in our current study we found that consultants being more experienced consider them self-confident, in case, if they would have to 22.8 11.6 13.2 4.8 47.6 0 5 10 15 20 25 30 35 40 45 50 antivirals antipyretics increased fluid intake secondary bacterial infection antibiotics symptomatic management and antivirals p e rc e n ta g e recommended management https://www.bing.com/ck/a?!&&p=73be95a13d4b44adjmltdhm9mty1otkxnjgwmczpz3vpzd0yztjjmdewmc0znta2lty2nzatmzvjmc0xmtvjmzewnjy4odemaw5zawq9ntuwoq&ptn=3&hsh=3&fclid=2e2c0100-3506-6670-35c0-115c31066881&u=a1ahr0chm6ly93d3cucg5hcy5vcmcv&ntb=1 https://www.bing.com/ck/a?!&&p=73be95a13d4b44adjmltdhm9mty1otkxnjgwmczpz3vpzd0yztjjmdewmc0znta2lty2nzatmzvjmc0xmtvjmzewnjy4odemaw5zawq9ntuwoq&ptn=3&hsh=3&fclid=2e2c0100-3506-6670-35c0-115c31066881&u=a1ahr0chm6ly93d3cucg5hcy5vcmcv&ntb=1 https://www.bing.com/ck/a?!&&p=8090c623e7433d00jmltdhm9mty2mde3njawmczpz3vpzd0yztjjmdewmc0znta2lty2nzatmzvjmc0xmtvjmzewnjy4odemaw5zawq9ntu5na&ptn=3&hsh=3&fclid=2e2c0100-3506-6670-35c0-115c31066881&u=a1ahr0chm6ly93d3cubmf0dxjllmnvbs8&ntb=1 https://www.bing.com/ck/a?!&&p=e284249dcfd93a96jmltdhm9mty2mde3njawmczpz3vpzd0yztjjmdewmc0znta2lty2nzatmzvjmc0xmtvjmzewnjy4odemaw5zawq9ntu5nw&ptn=3&hsh=3&fclid=2e2c0100-3506-6670-35c0-115c31066881&u=a1ahr0chm6ly93d3cubmf0dxjllmnvbs8&ntb=1 j aziz fatm med den college july – december 2022, vol. 4. no. 2 33 romaisa khalid et al manage hmpi. limitations: cross-sectional study itself is a limitation. conclusion this study shows the knowledge of medical practitioners working in punjab, pakistan is low and needs significant improvement. but considering the fact as being a newly emerging disease in asian countries the overall response of doctors was a bit reasonable. conflict of interest: none funding source: none recommendation: due to high alert by who there is an utmost need of training sessions for medical practitioners. infection control authorities, epidemiologists and community healthcare experts should urgently take effective measures and train the healthcare teams so that we would be ready to combat the hmpv. references 1. pastula dm, tyler kl. an overview of monkeypox virus and its neuroinvasive potential. ann neurol. 2022 ;92(4):527-531. doi: 10.1002/ana.26473. 2. balakrishnan vs. collaborating to improve monkeypox diagnostics. lancet microbe. 2022 ;3(10): e733. doi: 10.1016/s2666-5247(22)00256-7. 3. ladnyj id, ziegler p, kima e. a human infection caused by monkeypox virus in basankusu territory, democratic republic of the congo. bull world health organ. 1972;46(5):593-597. 4. bunge em, hoet b, chen l, lienert f, weidenthaler h, baer lr, steffen r. the changing epidemiology of human monkeypox-a potential threat? a systematic review. plos negl trop dis. 2022;16(2): e0010141. doi: 10.1371/journal. pntd.0010141. 5. jezek z, szczeniowski m, paluku km, mutombo m. human monkeypox: clinical features of 282 patients. j infect dis. 1987 ;156(2):293-8. doi: 10.1093/infdis/156.2.293. 6. gong q, wang c, chuai x, chiu s. monkeypox virus: a reemergent threat to humans. virol sin. 2022 ;37(4):477-482. doi: 10.1016/j.virs.2022.07.006. 7. meo sa, jawaid sa. human monkeypox: fifty-two years based analysis and updates. pak j med sci. 2022 ;38(6):14161419. doi: 10.12669/pjms.38.6.6775. 8. taylor l. monkeypox: who to rename disease to prevent stigma. bmj. 2022;377: o1489. doi: 10.1136/bmj. o1489. 9. thornhill jp, barkati s, walmsley s, rockstroh j, antinori a, harrison lb, et al. monkeypox virus infection in humans across 16 countries. 2022. n engl j med. 2022;387(8):679-691. doi: 10.1056/nejmoa2207323. 10. bukhari mh. the truth of monkeypox outbreak: a guide for the diagnostic laboratories, health care workers and community in pakistan. biomedica. 2022;38(2):53-56. 11. harapan h, setiawan am, yufika a, anwar s, wahyuni s, asrizal fw, et al. knowledge of human monkeypox viral infection among general practitioners: a cross-sectional study in indonesia. pathog glob health. 2020 ;114(2):68-75. doi: 10.1080/20477724.2020.1743037. 12. kmiec d, kirchhoff f. monkeypox: a new threat? int j mol sci. 2022;23(14):7866. doi: 10.3390/ijms23147866. 13. kozlov m. monkeypox goes global: why scientists are on alert. nature. 2022;606 (7912): 15-16. doi: 10.1038/d4158602201421-8. 14. alsanafi m, al-mahzoum k, sallam m. monkeypox knowledge and confidence in diagnosis and management with evaluation of emerging virus infection conspiracies among health professionals in kuwait. pathogens. 2022 ;11(9):994. doi: 10.3390/pathogens11090994. 15. alshahrani nz, algethami mr, alarifi am, alzahrani f, sheerah ha, abdelaal a, sah r, rodriguez-morales aj. knowledge and attitude regarding monkeypox virus among physicians in saudi arabia, a cross-sectional study. 2022 doi: https://doi.org/10.21203/rs.3.rs-1883068/v2 16. kaler j, hussain a, flores g, kheiri s, desrosiers d. monkeypox: a comprehensive review of transmission, pathogenesis, and manifestation. cureus.2022;14 (7): e 26531.doi: 10.7759/cureus.26531. 17. d'antonio f, pagani g, buca d, khalil a. monkeypox infection in pregnancy: a systematic review and metaanalysis. am j obstet gynecol mfm. 2022;5(1):100747. doi: 10. 10 16/j.ajogmf.2022.100747 authors’ contribution dr. romaisa khalid concept, study design, data collection, manuscript writing dr. sumera ehsan study design, data collection, literature search, manuscript writing ayesha khalid study design, data analysis, final review, overall supervision dr. khalid mahmood data analysis revised and revised and approved the article all authors are equally responsible for the validity of the data and approved the manuscript date of submission: 20-11-2022 revised: 11-12-2022 accepted: 15-12-2022 july december 2019; vol. 1, no. 2 j aziz fatm med den clg 77 review article malnutrition challenge therapeutic strategy syed hafeezul hassan summary malnutrition is a broad term which describes nutritional related diseases caused by over and under nutrition, found in the hospitals or in famines. therefore malnutrition can be categorized as over nutrition and obesity resulting into metabolic syndrome characterized by hyperglycemia, hypertension, dyslipidemia, hyperuricemia and decreased vitamin d in some cases. whereas under nutrition with inflammation can be as a result of chronic illness, acute illness/injury or simply decreased dietary intake when there is no inflammation. the initial assessment can be done by simple clinical measures such as recording weight and bmi and serum albumin estimation. the adjusted nutrition plan during sickness involves assessment of calories requirement under the circumstances and then to use appropriate nutrition or premade nutrition formulas to meet the new requirements during disease or after surgery. the therapeutic strategy which also includes nutrition assessment and treatment may result in decrease in complications hence decreased hospital stay and cost of treatment having better hospital outcomes. keywords: malnutrition, hypertension, dyslipidemia, hyperuricemia. introduction the world faces unequal distribution of food and essential resources. greater than 820 million people have not enough to eat.1 however at the same time epidemic of overweight and obesity was reported in various regions of developed as well as developing.1 in pakistan an alarmingly 24% of the population is undernourished due to insufficient food intake which makes them prone to acquire inflammatory and nutritional disorders. approx. 37.5 million people in pakistan are not receiving proper nourishment as recently estimated by the united nations food and agriculture organization (fao) state.2 world health organization (who) global health observatory states more than 52% women of child bearing age are anemic and at least 10.5 % children under 5 year age of both genders are suffering from wasting and stunted growth.2 ministry of national health services, aga khan university and united nations international children’s fund (unicef) has jointly launched a survey in 2018 to find nutrition challenges.3 nutritional imbalance leads to malnutrition. nutrients are vital for human beings and are essential for maintaining their functional capability. there is needed to take balance diet daily to fulfill their requirement.1,3 when one fasts, even for a day, he feels lack of energy by the end of the day, feels hungry and fatigued __________________________________________________________ correspondence: dr. syed hafeezul hassan (mbbs, mphil, phd) professor liaquat national medical college karachi email: hafeezul.hassan@lnh.edu.pk rendering him sluggish physically, emotionally and mentally. this is because his body adapts to the fasting state by reducing metabolic rate and activating different metabolic pathways to spare lean body mass. it is not advisable to lose proteins under any circumstances therefore conservation of proteins becomes body’s priority. the trouble begins when the body starts loosing proteins resulting into loss of muscle a condition known as sarcopenia consecutively resulting into low immune regulatory outcomes due to hypoproteinemia. pulmonary edema is more likely to develop and be more severe due to the low plasma protein concentration.4 malnutrition is broadly describes nutritional related disorders including the diseases triggered by over nutrition, to the extremes of under nutrition found in developed in developing countries.4 unbalanced nutrition with one or more micronutrient or mineral deficiencies are also malnutrition.5 therefore malnutrition can be categorized as over nutrition and obesity resulting into metabolic syndrome characterized by hyperglycemia, hypertension, dyslipidemia, hyperuricemia and decreased vitamin d in some cases. whereas under nutrition with inflammation can be as a result of chronic illness, acute illness/ injury or simply decreased dietary intake when there is no inflammation. in acute, chronic and transitional care settings, recognition and treatment of adult under nutrition are a primary concern.6 it typically occurs along a continuum of inadequate intake and increased requirements, impaired absorption, altered transport and altered nutrient utilization. the patient july december 2019; vol. 1, no. 2 j aziz fatm med den clg 78 may also present with inflammation, hyper-metabolic and hyper-catabolic conditions resulting into loss of lean body mass. american society of parenteral and enteral nutrition (a.s.p.e.n) with american academy of nutrition and dietetics published a consensus statement for hospitalized patients describing malnutrition as insufficient energy intake, weight loss, loss of subcutaneous mass, localized or generalized fluid accumulation and decreased functional status.7 therefore, malnutrition is a major contributor to increased morbidity and mortality, decreased function and quality of life, increased frequency and length of hospital stay and higher healthcare costs.8 a study conducted by luo and co-workers on association between baseline levels of amino acids and their metabolites and clinical outcomes in malnourished, hospitalized older patients showed certain amino acids were associated with clinical and nutritional outcomes and could potentially be used in a predictive fashion.9 the therapeutic strategy which also includes nutrition assessment and treatment may result in decrease in complications hence decreased hospital stay and cost of treatment having better hospital outcomes. the adjusted nutrition plan during sickness involves assessment of calories requirement under the circumstances and then to use appropriate nutrition or premade nutrition formulas to meet the new requirements during disease or after surgery. the expertise of a trained dietitian/ nutritionist may play a vital role to supplement nutrition under changing metabolic demands. the evidence shows that an appropriate nutrition intervention results in speedy recovery, lesser complications, shorter hospital stay and hence reduced cost of treatment.10,11 conflicts of interest: none. references 1. food and agriculture organization of the united nations. the state of food security and nutrition in the world.2019. www.fao.org›state-of-food-security-nutrition 2. malnutrition in pakistan the hidden hunger, cabinet division, govt. of pakistan, health services academy 2012; 2 (2) http://www.tbl.com.pk/malnutrition-in-pakistan-thehidden-hunger 3. national nutrition survey 2018 key findings report. a summary of the key insights and statistics. https://www.unicef.org/pakistan/reports/nationalnutrition-survey-2018-key-findings-report 4. hugh o' brodovich md, in kendig's disorders of the respiratory tract in children (ninth edition), 2019 pages 580-595 https://doi.org/10.1016/b978-0-323-448871.00036-5 5. allison sp. malnutrition, disease and outcome. nutrition 2000;16:590-593 6. jensen gl, iirtallo j, compher c, et al. adult starvation and disease-related malnutrition: a rational approach for etiology-based diagnosis in the clinical practice setting from the international consensus guideline committee. jpenj parenter enternal nutrition.2010;34:156-159 7. jane v, peggy g, gordon j, ainsley m, marsha s. identification and documentation of adult malnutrition, consensus statement academy of nutrition and dietetics and aspen. journal of parenteral and enteral nutrition 2012; (36)3:275-283. 8. blackburn gl, bristrian br, maini bs, schlamm ht and smith mf. nutritional and metabolic assessment of hospitalized patients. jpen 1977; 1:11-22 9. m. luo, s.l. pereira, g.e. baggs, j.l. nelson, n.e. deutz. association between baseline levels of amino acids and their metabolites and clinical outcomes in malnourished, hospitalized older patients. clinical nutrition 2018; (37): s1-s23 10. gerard e. mullin, linlin fan, suelasulo, jamie partridge. the association between oral nutritional supplements and 30-day hospital readmissions of malnourished patients at a us academic medical center journal of the academy of nutrition and dietetics 2019;119 (7): 1168–1175 doi: https://doi.org/10.1016/j.jand.2019.01.014 11. asim m, nawaz y child malnutrition in pakistan: evidence from literature.children (basel). 2018; 5(5). pii: e60. doi: 10.3390/children5050060. review. author’s contribution: dr. syed hafeezul hassan concept of review and literature review. manuscript writing and final version approval. accountable for provided information. syed hafeezul hassan http://www.tbl.com.pk/malnutrition-in-pakistan-the-hidden-hunger http://www.tbl.com.pk/malnutrition-in-pakistan-the-hidden-hunger https://www.unicef.org/pakistan/reports/national-nutrition-survey-2018-key-findings-report https://www.unicef.org/pakistan/reports/national-nutrition-survey-2018-key-findings-report https://www.sciencedirect.com/book/9780323448871 https://www.sciencedirect.com/book/9780323448871 https://doi.org/10.1016/b978-0-323-44887-1.00036-5 https://doi.org/10.1016/b978-0-323-44887-1.00036-5 https://doi.org/10.1016/j.jand.2019.01.014 https://www.ncbi.nlm.nih.gov/pubmed/29734703 https://www.ncbi.nlm.nih.gov/pubmed/29734703 july december 2019; vol. 1, no. 2 j aziz fatm med den clg 67 original article frequency and association between different abo blood groups with hepatitis c rana muhammad tahir salam, rooha tariq, sarwat jahan, sarwat bibi, humaira ahmad abstract objective: this study aims to find the frequency and association of hepatitis c with different abo blood groups. methodology: this retrospective study of six months duration was conducted at aziz fatimah hospital faisalabad after approval from the ethical committee. blood bank data was retrieved and blood reports for all the blood borne diseases were analyzed. only reports with hcv positive along with their respective blood groups were analyzed by spss 22. frequency and percentages of hepatitis c was estimated. association of hcv with blood group was determined using chi-square test. p value ≤0.05 was taken as significant. results: data from 1000 reports of screened blood showed 52 (5.2%) reports seropositive positive for hcv. among these, 15 (28.8%) reports of blood group a showed hcv seropositivity. however, 18 (34.6%) respondents with blood group b were hcv seropositive. hcv cases in blood group ab were 7 (13.5%). there were 12 (23.1%) hcv positive subjects with blood group o. conclusion: hcv is not significantly associated with blood group. keywords: hepatitis c, blood borne diseases, blood group. introduction hepatitis c disease is a life threating disease which is caused by blood-borne hepacivirus c. it is seeking a global health attention especially in the developing countries where this disease is rapidly spreading day after day. it usually progresses to hepatocellular carcinoma which is definitely responsible for early mortality of the affected subjects. in underdeveloped countries, it always remained a burning health issue among the health authorities due to careless attitude towards health and hepatitis c management.1 this is also attributed to low literacy rate and lack of health awareness programs concerning this issue. in pakistan, its prevalence is 4.8% and is increasing at a whirlwind ____________________________________________________________ dr. rana muhammad tahir salam (mbbs) sonologist aziz fatimah trust hospital, faisalabad dr. rooha tariq (mbbs) demonstrator aziz fatimah medical and dental college, faisalabad dr. sarwat jahan (mbbs, mphil) assistant professor aziz fatimah medical and dental college, faisalabad dr. sarwat bibi (mbbs, fcps) assistant professor aziz fatimah medical & dental college, faisalabad dr. humaira (mbbs, fcps) assistant professor aziz fatimah medical & dental college, faisalabad correspondence: dr. rooha tariq email: rooha_93@hotmail.com rate. it prevails both in community subjects as well as in health care providers.1,2 it is believed to be the second highest health concerning issue in the world.3 however, punjab has the highest prevalence (17%) among the provinces of pakistan, and major proportion of this high prevalence was from faisalabad district.3 in this region, extensive transmission of this disease needs critical understanding of its epidemiology and cost effective prevention and also the treatment interventions. mounting evidence has suggested an association of abo blood groups with blood borne infectious diseases but outcomes were different from study to study. it is well documented that certain blood group acts as receptor for attachment of certain viruses and bacteria.4 concerning the pathogenesis of hcv and its association, it is believed that membrane of the red blood cells and microorganism interaction is responsible for receptor adherence and response modulation.5 due to increasing prevalence of this life threatening condition, it is crucial to take essential steps for the awareness and prevention of hepatitis at community level. screening for hepatitis at prevalent regions should be adopted on immediate basis in order to fulfill the international target for elimination of hcv. hence, our study aims to find the association of hcv with different abo blood groups and to identify the group at more risk for hepatitis c. methodology this retrospective study of six month duration was conducted at aziz fatimah hospital, faisalabad. ethical approval from the administrative authority was mailto:rooha_93@hotmail.com july december 2019; vol. 1, no. 2 j aziz fatm med den clg 68 taken. data of blood bank of hospital from july 2018 to november 2018 was retrieved from the central data base record of the hospital. total 1000 blood reports of screened blood during this duration for all the blood borne diseases were reviewed. data concerning seropositive tests for hepatitis b surface antigen (hbs ag), hiv, syphilis, and malaria were excluded. reports with reactive test for hcv were included in the study. all reactive test reports for hcv along with their respective blood groups were documented for further analysis. informed consent of the patient was not needed as including patient’s data was anonymized.6 data was transferred to the spss 22 for further analysis. frequency and percentages of hepatitis c was estimated. association of hcv with blood group was determined using chi-square test. p value ≤0.05 was taken as significant. results during the six month of study duration total 1000 reports of screened blood were retrieved from the blood bank. only 52 (5.2%) reports were seropositive for hcv out of total 1000 reports. distribution of hepatitis c among the abo blood groups are highlighted in table-1. hepatitis c was most commonly found in subjects with blood group ab followed by blood group a. no association of abo blood group was noted with hepatitis c. (p value 0.49) table 1: frequency of hepatitis c among abo blood groups (n=1000) abo blood groups hepatitis c (anti hcv) frequency n (%) seropositive frequency n (%) seronegative frequency n (%) a 233 (23.3%) 15 (6.4%) 218 (93.6%) b 384 (38.4%) 18 (4.6%) 366 (95.4%) ab 94 (9.4%) 7 (7.4%) 87 (92.6%) o 289 (28.9%) 12 (4.2%) 277 (95.8%) p value 0.49 statistically significant value at p <0.05 discussion hepatitis is a disease which is seeking attention especially in developing countries. pakistan is ranked highest among the affected countries with overall prevalence of 5.46% in punjab, sindh: 2.55%, khyber pakhtunkhwa: 6.07%, baluchistan: 25.77%, and federally administrated tribal areas: 3.37%. punjab is the 3rd highest among these provinces. the most affected district in the province of punjab is faisalabad.7 hence, here comes the need to evaluate the reason of speedy spread of hcv particularly in this district and establish if there is any association of this disease with blood group or if it is spreading due to the mere lack of awareness about its epidemiology. study conducted at peshawar by zulfishan batool and his colleagues found 1.30% hcv in their setting and this was a major difference with the current study showing that data only from one setting showed 5.2% of hcv affected subjects.4 our study did not find association of hcv with specific blood group. similar to our these results, mohammad ali f and his colleagues also did not found any significant association of hcv with blood groups.8 gao x did systemic review of multiple papers also did not find significant association with blood groups.9 however, some studies are also available that show that studies conducted in small size population show association of hcv with blood group.8,10 sreedhar and his colleagues found high frequency of hcv in blood group o.11 contrary to these results, our study showed higher frequency of hcv in blood group ab. however, o blood group had least number of hcv affected subjects. while, sreedhar et al also showed that there was a least number of hcv seropositive subjects with blood group ab and this was in disagreement to our results.11 conclusion hcv is more prevalent among the subjects with blood group ‘ab’ followed by blood group a. however, abo blood groups are not associated with hepatitis c. funding source: none. conflicts of interest: none. references 1. shakeel h a, maqsood h , ali b, khan a r. international journal of research in medical sciences shakeel hs et al. int j res med sci. 2018;6(4):1114-1118 2. al kanaani z, mahmud s, kouyoumjian sp, abu-raddad lj. the epidemiology of hepatitis c virus in pakistan: systematic review and meta-analyses. r soc open sci. 2018;5(4):180257. doi: 10.1098/rsos. 3. amsal a, altaf b, ali f a. seroprevelance of hepatitis b&c and its association with stroke in local population. j aziz fatm med den clg 2019;1:(1):9-12. 4. batool z, durrani sh, tariq s. association of abo and rh blood group types to hepatitis b, hepatitis c, hiv and syphilis infection, a five year’ experience in healthy blood donors in a tertiary care hospital. j ayub med coll abbottabad 2017;29(1):90–92. 5. gerald l, douglas m. principles and practice of infectious disease, churchill, 5th ed. 2000;1:39. rana m tahir salam et al. july december 2019; vol. 1, no. 2 j aziz fatm med den clg 69 6. borovecki a, mlinaric a, horvat m, supak smolcic v. informed consent and ethics committee approval in laboratory medicine. biochem med (zagreb). 2018;28 (3):030201.doi: 10.11613/bm.2018.030201. review. 7. arshad a, ashfaq ua. epidemiology of hepatitis c infection in pakistan: current estimate and major risk factors. crit rev eukaryot gene expr. 2017; 27(1); 63-77 doi:10.1615/critreveukaryotgeneexpr.201701895. review. 8. mohammadali f, pourfathollah a. association of abo and rh blood groups to blood-borne infections among blood donors in tehran-iran. iran j public health. 2014; 43(7):981-989. 9. gao x, cui q, shi x, su j, peng z, chen x, et al. prevalence and trend of hepatitis c virus infection among blood donors in chinese mainland: a systematic review and meta-analysis. bmc infect dis. 2011; 11. doi: 10. 1186/1471-2334-11-88. 10. el–gilany ah, el–fedawy s. blood borne infections among student voluntary blood donors in mansoura university, egypt. east mediterr health j. 2006;12(6):742748. 11. sreedhar babu kv, bandi s, kondareddy s, madithadu a. association of abo and rh blood groups to hbv, hcv infections among blood donors in a blood bank of tertiary care teaching hospital in southern india: a retrospective study. int j res med sci. 2015;3(7):1672-1676. doi: http://dx.doi.org/10.18203/2320-6012.ijrms20150249 abo blood groups & hepatitis c author’s contribution: dr. rana muhammad tahir salam data collection and integrity of data. manuscript writing and approval. dr. rooha tariq statistical analysis, interpretation of results, formulation of tables and manuscript writing. dr. sarwat jahan statistical analysis, interpretation of results, editing and formatting the manuscript. dr. sarwat bibi data collection, integrity of data, manuscript writing, review and approval. dr. humaira ahmad data collection, integrity of data, manuscript writing, review and approval. july december 2019; vol. 1, no. 2 j aziz fatm med den clg 60 original article comparison of academic performance among boarders and day-scholars benash altaf, anam rehman, farah amir ali abstract objective: the aim of the study is to compare the academic performance of boarders and day scholars of a medical college. methodology: it is a retrospective comparative study conducted at a private medical college, in faisalabad from january 2019 to september 2019. the study comprised of 214 students that included boarders and day scholars of first year and second year from medical college. aggregate mean scores of student’s result were categorized into three level for comparison between day scholars and boarders; level i ≤50%, level ii 50%-70%, level iii ≥70%. results: out of 214 students, 132 (62%) were day scholars and 82 (28%) were boarders. from total of 132 day scholar students, 38 (28.8%), 84 (63.6%) and 10 (7.6%) students overall aggregates were falling in <50%, 50%70% and >70% categories, respectively. from total of 82 boarder students, 45 (54.9%), 34 (41.5%) and 3 (3.7%) students overall aggregates were falling in <50%, 50-70 and >70% categories, respectively. conclusion: home environment has positive impact on academic performance. keywords: academic performance, boarders, day scholars, aggregates. introduction human personality is shaped by the lifelong experiences. human behavior is formed and modified by their life experience. family plays a pivotal role in personality building and later on society comes to play its role in behavior modification. hence, some become effective member of this society while some prefer live in isolation.1 roman catholics and anglicans are believed to be the pioneers for starting the boarding system in 20th century.2,3 their vision for introducing this system was to help the students in studies whenever they seek help from teachers, their character and confidence building, coping with new environment and hoe to become social. they observe good out comes including student confidence, maturity and independent decision making skills.3 however, in contrast to these benefits of boarding, some studies highlighted the students suffering from low selfesteem, home sickness resulting in poor academic ___________________________________________________________ dr. benash altaf (mbbs, mphil) assistant professor aziz fatimah medical and dental college, faisalabad dr. anam rehman (mbbs, mphil) senior demonstrator aziz fatimah medical and dental college, faisalabad dr. farah amir ali (mbbs, mphil) professor aziz fatimah medical and dental college, faisalabad correspondence: dr. benash altaf email. altafbenash@gmail.com performance.4 moffat and his colleagues identified that hostel life plays a very important role for maturing the personality and student mind as it gives healthy competitive environment with other pupils and peers, motivating students to improve their performance.5 according to some researches, day scholars perform their day to day task in better way as they are boosted with family and friends support.3 while on the other hand, boarders; living in hostels are thought to be positively correlated with academic performance as it keeps them away from family, relatives and unnecessary gatherings, responsible for a significant wastage of time; thus they can easily study at hostel without any interference.6,3 current study was conducted to evaluate that which environment was favorable for students to obtain appreciable scores in undergraduate medical education. methodology this retrospective comparative study was conducted at aziz fatimah medical & dental college, faisalabad after taking administrative authority approval. the studied population of 214 mbbs students of first year and second year, including boarders and day scholars recruited by universal sampling of private based medical college. the aggregate of total formative seven physiology tests conducted from january to september 2019 were evaluated, and the cumulative aggregate score were compared. written paper comprised of two mailto:altafbenash@gmail.com july december 2019; vol. 1, no. 2 j aziz fatm med den clg 61 parts, multiple-choice questions (mcqs) and short essay questions (seqs). to minimize the element of bias, structured key was given to all examiners to evaluate the papers. then, list of boarders and day scholars was provided by the student affairs section. mean aggregate scores were categorized into three level for comparison between day scholars and boarders; level i ≤50%; level ii 50%-70%, level iii ≥70%. statistical analysis was done using spss version 21.0. mean of aggregates was compared by applying independent t-test and percentages were compared using chi-square. p value ≤0.05 was taken as significant. results out of 214 students, 132 (62%) were day scholars and 82 (28%) were living in hostels. from total of 132 day scholar students, 38 (28.8%), 84 (63.6%) and 10 (7.6%) students overall aggregates were falling in <50%, 5070% and >70% categories, respectively. from total of 82 hostel students, 45 (54.9%), 34 (41.5%) and 3 (3.7%) overall aggregates were falling in <50%, 5070% and >70% categories, respectively. the result shows the comparison between the boarders and dayscholars which is illustrating the comparison of overall aggregate scores and student categories, shown in table-1 table 1: comparison of overall aggregates scores with study groups (n=214) study groups categories of overall aggregates scores <50% 50-70% >70% n (%) n (%) n (%) day scholars 132 (62%) 38 (28.8%) 84 (63.6%) 10 (7.6%) boarders 82 (28%) 45 (54.9%) 34 (41.5%) 3 (3.7%) p value 0.001*, p ≤0.05 is significant the results show that day scholars students overall aggregate results were more competent than boarder students. chi square test was used to check the significant association between overall aggregate and residence of the medical students. p value ≥0.001 showed that there was a significant association between overall aggregate categories and current residence of medical students. mean±sd of the overall aggregate of the boarder students and day scholar students were 55.36±11.85 and 45.35±17.5 respectively. mean comparison showed overall mean aggregate of day scholars higher than the boarder students. means of the aggregate of boarder and day scholars was compared by t-test, a significant difference was found between means aggregate of boarder and day scholars with p value < 0.0001. mean difference shown in bar chart between day scholars and boarder students respective to overall aggregates is shown in figure 1. figure 1: comparison of mean scores among study group (n=214) p value =0.0001*, p ≤ 0.05 is significant discussion in developing countries, students are believed to have the potential for doing something fruitful that might prove beneficial for human resource on extensive scale. they can seek education living with their parents and might travel distant areas to achieve their academics. hostel is a dwelling where students live in a supervised environment.3 hostel life definitely affects students’ outcomes in terms of his/her academics as well as their behavior as these students alone facing different problems. however, day scholars who live with their parents do not face issues like hostel fooling, unhealthy mess, and home sickness, but they surely do envy the freedom and independence of their hostel collegues.7 jacob and his colleagues found better academic performance in boarder than the day scholars.3 study conducted by mane and his colleagues was also in favor of boarder in terms of better academic scores when they compared academic grades with boarder.8 while on the other hand, this study was contrary to these results showing that day scholars’ performance was much better than the boarders. however study conducted in pakistan in peshawar based medical college did not find any significant difference of academic performance among day scholar and boarders.9 similar to our result, riya and her colleagues stated that student academic performance is effected more in boarder as they are at risk of developing 55.36± 11.85 45.35 ± 17.72 0 10 20 30 40 50 60 day scholars boarders m e a n s co re s benash altaf et al. july december 2019; vol. 1, no. 2 j aziz fatm med den clg 62 depression and bad habits which may be due to lack of parents and sibling support, new environment and below the standard mess.10 conclusion day scholars show comparatively better academic performance than the boarders. funding source: none. conflicts of interest: none. references 1. amina i, asir a. a qualitative study investigating the impact of hostel life. ijemhhr. 2015; 17(22); 511-515. 2. bahadar n, mahnaz w, jadoon s. a comparative analysis of the behaviours and performance of day scholars and boarders students at secondary school level. am j educ res. 2014; 2(8); 600-602. 3. jacob am, kaushik a. a comparative study to assess the health status and academic progress among day scholars and boarders in a selected college of nursing in new delhi. int. j. nurs. midwif. res. 2017; 4(2); 2-8. 4. perveen s, kazmi sf.personality dynamics of boarders and day scholars who belong to madrasah and public school. acad res int. 2011; 1(1): 57-72. 5. moffat. overall personality development of the students is primed by the boarding school uk [online] 2011 [cited 2015 jun 16]. available from: http//www.buksia.com/ articles/434153_overall personalitydevelopment –of -the students-is primed-by-the-boarding-school-uk. 6. rehman a, siddiqui a. a comparison between day scholars and hostelites. [online] 2013 [cited 2015 jun 16]. available from: https//prezi. com/ 4ppkjokj2wrj/untitledprezi/ 7. ali s , haider z , munir f , khan h , ahmed a. factors contributing to the students’ academic performance: a case study of islamia university subcampus. am educ res j. 2013; 1(8); 283-289. 8. mane d, kakade sv, alate m. assessment of study skills between day scholars & boarders student among nursing students .ijsr issn (online): 2319-7064 issn (online). 2018; 7(8); 348. doi: 10.21275/art2019332. 9. faisal r, shinwari l, izzat s. academic performance of day scholars versus boarders in pharmacology examinations of a medical school in pakistan. j pak med assoc 2016;(9); 66. 10. bhattacharya r, bhattacharya b. psychological factors affecting student’s academic performance in higher education among students.ijoart.2015;4(1); 2349-3585. academic performance of boarders & day scholars author’s contribution: dr. benash altaf statistical analysis, interpretation of results, formulation of tables and manuscript writing. dr. anam rehman interpretation of results and manuscript writing. dr. farah amir ali integrity of data, interpretation of results, formatting the manuscript and proof reading. j aziz fatm med den college july – december 2022, vol. 4. no. 2 14 original article use of single shoulder handling bag : scoliosis and musculos keletal pain in school going children. “a cross sectional study” amna khalid, abid rashid, sultan mahmood, jawad ahmad, sana sarfraz, sultan ayaz abstract objectives: the objectives of the study were to assess the frequency of musculoskeletal pain, and to check whether single strapped bags are culprit of causing scoliosis in school going children or not as compared to other types of school bags i.e. double strapped and trolley type bags. methodology: the study design was an observational cross-sectional. the process of data collection from the school going children (n=398) between the ages of 8 and 16 years was carried out in the government schools of the faisalabad through a simple random sampling technique. measurements of weight were taken through spring scale and subjective self-administered questionnaire was completed from each student along with cobb’s angle to measure the curvature and adam forward bend test was also performed on each pupil. results: majority of the students used to carry single strapped bag with average value of 50.5% while double strapped bag with average percentage of 48.0%. most of the students were used to carry bag on one side of shoulder with an average value of 68.3% and only 31.7% carried bag on both sides of shoulders. most of the children reported pain in the neck and shoulder region with average percentage of 73.6% and in back/buttock were 105 with percentage of 26.4%. 92.5% of the children stated that their pain was relieved when they took off their bags and 51.3% were used to take medicine for pain reduction. on visual analogue rating scale, 57.8% of the children reported the moderate level of pain. mean ± sd of students using single strapped and double strapped bags were 2.2438± 0.579 and 1.7958 and 0.64497. adam forward test was also most frequently positive in students using single strapped bag as compared to other types of bags (p value = 0.000) reflecting scoliosis conclusion: students majority who used to wear one side shoulder bag were prone to suffer scoliosis and pain in neck and shoulder region. keywords: scoliosis, musculoskeletal pain, school bags, children introduction school going children carry heavy backpacks on their shoulders as an integral part of their daily routine.1 school bags consist of mandatory stuff amna khalid dpt, mphil (pt) lecturer, of physical therapy government college university faisalabad dr. abid rashid mbbs, fcps, phd professor, of medical sciences government college university faisalabad dr. sultan mahmood khan mbbs, ms (surgery) assistant professor aziz fatimah medical & dental college/ hospital faisalabad, jawad ahmad, dpt, ms (pt) department of physical therapy government college university faisalabad sana sarfraz dpt, ms (pt) department of physical therapy government college university faisalabad dr. sultan ayaz phd associate professor, of medical sciences, government college university faisalabad correspondence: dr. abid rashid email: drabidrashid37@gmail.com containing books, copies and other helping material but these advantageous learning assets can cause a number of harmful effects on the child’s health, growth, and overall physical appearance. school bags are available in numerous sizes, shapes, lengths and styles but they can cause a serious or life-threatening condition known as scoliosis. the word scoliosis is derived from a greek word which means the crooked. significantly, out of every 100 people 03 persons struggle against some form of scoliosis.1 the heavy load of bags carrying on back results in associated compensatory changes in posture causing forward trunk inclination to maintain the balance while in standing or walking.2 it is important to find an inter-relationship between the ways of carrying backpacks, symmetry or asymmetry, weight carrying on back, and the posture assumed while carrying the schoolbags.1 it was found that the trunk forward bending was j aziz fatm med den college july – december 2022, vol. 4. no. 2 15 amna khalid et al increased proportionally with increase in the weight and walking distance, causing more stresses on the vertebral column and subjecting the spine to a list of problems more commonly the back pain.2 at present, there is emerging evidence that the children are greatly influenced by both acute and chronic low back torment. the rising number of children giving back pain complaints is connected with static physical activities like sitting, standing, or lifting loads during day-to-day routine.2 scoliosis is a major worldwide problem. as a matter of fact, 28 million patients are affected and children suffer from scoliosis in the age of 1016 years with overall prevalence of 0.47% to 5.2% in present literature. in united states, the overall cases reported is approximately more than 5.88 million which ranges from 2.5% to 60%. it is anticipated that in future the number of patients will increase hysterically. it is predicted that there will be over 36 million scoliosis patients in 2050.3 the goal of treatment in children is to prevent progression. for children with a scoliosis of 20° or more, a brace is usually recommended. for a scoliosis of 45° or more, surgery may be necessary. the intervention for adults having scoliosis is based on an individual's specific needs, with physical therapy and supportive braces contributing a relatively trivial role.4 screening adolescents in middle and high schools for idiopathic scoliosis is important for early identification, prevention of future deformities, and healthy body growth.5 therefore, the aim of this study was to check the frequency of musculoskeletal pain and scoliosis due to wearing heavy schoolbags, assessing the ways of carrying bags and bring the awareness among pupils and their guardians. methodology it was a cross-sectional study. the duration of this study was 6 months after approval from research and ethical review board. in this research, total 398 students were surveyed, in which 148 were males and 250 were females. frequency of scoliosis and musculoskeletal pain were examined in students of age group of 8-15 years in government schools of faisalabad. written informed consent were taken from all institutes from where data had to be collected. geographical or economic representation were not special considered. all students received detailed understanding and information regarding the purpose of research. simple random sampling was used. the sample size is 398, calculated with margin of error 5%, and confidence level of 95%. the estimated population of school going children is 200000, in faisalabad pakistan. the sample size is calculated according to the following formula, x = z(c/100)2r (100-r) n = n x/ ((n-1) e2 + x) e = sort [(n n) x/n (n-1)] a self-made questionnaire was used containing information regarding demographics, school bag type, way of wearing bag, duration of carrying bag, distance to class, use of stairs carrying bag, pain in regions, pain in past few days, restriction in physical activity, restriction in extracurricular activity, leave from school due to pain, pain reduction, treatment or medication for pain, pain on vas, difficulty in breathing, difficulty in standing straight, difficulty in walking, difficulty in toe touching, for collection of data from different public schools. measurements of weight were taken through spring scale and subjective self-made questionnaire was completed from each student along with cobb’s angle to measure the curvature. adam forward bend test was also performed on each pupil, they were asked to lean forward keeping feet together and their knees straight with arms hanging by side. any deviation in spinal curvature was noted. frequencies and percentages were measured for all variables and in order to check the association based on gender, the chi square analysis was performed. the data was statistically analyzed via the ibm spss version 23 software. results out of total sample size 398, the male frequency was 37.2% and female frequency was 62.8%. the frequency of school bag types with single strapped bag was 50.5%, double strapped bag was 48.0% and trolley bags was 1.5%. it showed that most of the students carried single strapped bags with next popularity of double strapped bags and lesser numbers were found with trolley ones. students with percentage of 68.3% were found to wear bag on side of the shoulder while 31.7% were found to carry school backpack on both sides of the shoulders. the weight of school bag was divided j aziz fatm med den college july – december 2022, vol. 4. no. 2 16 school bags vs scoliosis & musculoskeletal pain into three categories ranging from 5kg, 10kg, and 15kg. higher frequency distribution was seen in those students whose school bag weight was 5kg, next was 10 kg and least frequency distribution. table 1: frequency distributions of different variables of the study (n = 398) variables frequency (percent) n (%) gender male female 148(37.2) 250(62.8) education/class middle group higher group 40(10.1) 358(89.9) what is your school bag type? single strapped bag double strapped bag trolley bag 201(50.5) 191(48.0) 6(1.5) do you wear bag on one side or both sides of the shoulders? one side both side 272(68.3) 126(31.7) what is the weight of your bag? 5kg 10kg 15kg 187(47.0) 160(40.2) 51(12.8) what is the duration of carrying bag on your back every day? 5minutes/day 10minutes/day 15minutes/day 77(19.3) 90(22.6) 231(58.0) how much is your distance from gate to classroom while carrying bag? 50 steps by foot 70 steps by foot 90 steps by foot 227(57.0) 116(29.1) 55(13.8) do you use stairs to reach class or not? yes no 236(59.3) 162(40.7) do you feel pain in your___? neck/shoulder back/buttock 293(73.6) 105(26.4) have you had pain in the past few days? yes no 303(76.1) 95(23.9) do you feel pain in your physical activities? yes no 251(63.1) 147(36.9) does your pain reduce when you take rest/take off your bag? yes no 230(57.8) 168(42.2) do you take any medication/treatment for pain? yes no 204(51.3) 194(48.7) if you have pain, then rate pain on vas no pain moderate pain worst pain 79(19.8) 230(57.8) 89(22.4) do you feel difficulty in walking? yes no 207(52.0) 191(48.0) concerning region of pain, distribution of respondents: feeling pain in neck/shoulder 293(73.6) back/buttock 105(26.4) regarding uneven shoulder height, distribution of respondents: yes no 95(23.9) 303(76.1) positive finding of adam forward test yes no 98(24.6) 300(75.4) with respect to difficulty in breathing, distribution of respondents: yes no 30(7.5) 368(92.5) do you feel difficulty in standing up perfectly straight? yes no 97(24.4) 301(75.6) do you feel difficulty in walking? yes no 191(48.0) 207(52.0) do you feel difficulty in touching your toes? yes no 281(70.6) 117(29.4) table 2: comparison of variables based on school bag type variable response single strapped bag n (%) 201 (50.5) double strapped bag n (%) 191 (48) trolley bag n (%) 6 (1.5) p value do you feel pain in your___? neck/ shoulder 152 (75.6) 138 (72.3) 3 (50.0) 0.003* back/ buttock 49 (24.4) 53 (27.7) 3 (50.0) uneven shoulder height? yes 53 (27.7) 43 (21.4) 2 (33.3) 0.000* no 138 (72.3) 158 (78.6) 4 (66.7) do you feel any difficulty in breathing ? yes 99 (49.3) 61 (31.9) 2 (33.3) 0.002* no 102 (50.7) 130 (68.1) 4 (66.7) do you feel difficulty in standing up perfectly straight? yes 50 (26.2) 46 (22.9) 1 (16.7) 0.680 no 141 (73.8) 155 (77.1) 5 (83.8) do you feel difficulty in walking? yes 126 (62.7) 78 (40.8) 3 (50.0) 0.000* no 75 (37.3) 113 (59.2) 3 (50.0) do you feel difficulty in touching your toes? yes 157 (78.1) 119 (62.3) 5 (83.3) 0.002* no 44 (21.9) 72 (37.7) 1 (16.7) positive findings of adam forward test yes 167 (83.1) 81 (42.4) 3 (50.0) 0.000* no 34 (16.9) 110 (57.6) 3 (50.0) was of 15kg weight. the percentages of 5kg, 10kg and 15kg weight were 47%, 40.2% and 12.8% respectively. the distance was categorized into steps as 50 steps by foot, 70 steps by foot and 90 j aziz fatm med den college july – december 2022, vol. 4. no. 2 17 amna khalid et al steps by foot. their frequency distributions were found to be 227, 116 and 55 respectively with percentage of 57.0%, 29.1% and 13.8%. those who used stairs to reach class were found with frequency distribution of 236 with percentage of 59.3%. while on the other hand, students who did not use stairs to reach class were found to have frequency distribution of 162 with percentage of 40.7%. the number of students felt pain in neck/shoulder were 293 and in back/buttock were 105 with percentage of 73.6 to 26.4 respectively. frequency of student who felt pain during physical activity was 250 and those who did not was 147 with percentage of 62.8 and 36.9 respectively. frequency of taking leave was 179 and those who did not was 218 with percentage of 45.0 and 54.8 respectively. frequency of taking medicine for pain was 204 and those who did not was 193 with percentages of 51.3 and 48.5 respectively. the number of students feeling moderate pain were higher i.e. 57.8% as compared to no pain and severe pain. frequency of feeling difficulty in breathing due to pain was 162 and those who did not was 236 with percentages of 40.7 and 59.3 respectively. frequency of difficulty in standing up perfectly upright was 97 and those who did not was 301 with percentage of 24.4 and 75.6 respectively. frequency of difficulty in toe touching due to pain was 281 and those who did not was 117 with percentages of 70.6 and 29.4 respectively. on assessing the students for scoliosis, we found that 24.6% have positive adam forward test,23.9% have uneven shoulder ,24.4% % students were not able to stand straight perfectly (table 1) on visual analogue rating scale, 57.8% of the children reported the moderate level of pain. on comparison of vas score among the students using single strapped and double strapped bags we found higher scores in students using single strapped bags (table 1). mean ± sd of students using single strapped and double strapped bags were 2.2438± 0.579 and 1.7958 and 0.64497. table 2 shows comparison of sign and symptoms of scoliosis among the students carrying different types of bags. results show that the students carrying single strapped bag have more pronounced sign and symptoms of scoliosis as compared to other types of bags which are double strapped and trolley type bags with significant p values. adam forward test was also most frequently positive in students using single strapped bag as compared to other types of bags (p value= 0.000) discussion this study was conducted to describe the relationship between the spinal deformity i.e. scoliosis and school bag pack in school going children aged 8-16 years. both male and female students were assessed for the scoliosis by performing adam’s forward bend test. each of the student was asked to bend forward in horizontal plane and the spine of the student was assessed by standing behind the student and looking for any changes in the spinal curve. after assessing through forward bend test, we found a positive finding regarding scoliosis i.e. most of student were prone to scoliosis due to carrying heavy bags or other factors like bad posture. and it was supported by another study who reported that, basically it affected by carrying heavy bags as children are in growing age. 3.4% of students gave positive finding about scoliosis by adam’s forward bend test and were asked to go for referral physician.6 different studies showed different results of adam’s forward bend test for scoliosis. some studies showed least percentage of prevalence of scoliosis i.e. 1.4% to 2.5% and on contrary, some depicted higher prevalence of scoliosis i.e. 26% to 66% by using adam’s forward bend test. 7 when students were asked for whether they carry bag on both shoulders or on one side of shoulder, then a greater frequency of 272 of those students was found who used to carry school bags on one side with average value of 68.3%. a lesser percentage value of 31.7% was found for those students who used to wear school bag packs on both sides of shoulders. on the other hand, a study reported different results which showed that the majority of the students carry double strapped bag packs, having symmetrical weight on both sides of shoulders with average percentage value of 58.4.8 pain intensity was assessed using visual analogue scale (vas) ranging from 0 (no pain) to 10 (worst pain). pain was localized to the regions of neck/shoulder and back/buttock and students reported pain where they felt the pain over. the higher frequency distribution of 293 with average value of 73.6% out of 398 was found in the neck and shoulder j aziz fatm med den college july – december 2022, vol. 4. no. 2 18 school bags vs scoliosis & musculoskeletal pain region as compared to the back and buttock region whose average percentage was 26.4% with frequency distribution of 105. a study reported pain intensity of back from 0.952-6.9, shoulder pain intensity ranging from 1.799-7.855 and neck pain severity was ranging from 0-5.166 out of 010 scale values.1 another study reported that low back pain is found primarily in the students and the decreased strength of abdominal muscles and back extensors with reduced flexibility of hamstrings muscles are the culprit. they supported their study with the research of lopes who stated that the school bags cause the pain in various regions of the body including neck, shoulders and back with average value of 83%. further negrini and carabalona et al, reported that 46.1% of the school going students was found to have lumbar pain due to wearing school bags. the students in the present study also reported difficulty in the physical activities. a majority of students stated the difficulty in physical activities with average value of 62.8% with frequency of 250 out of 398 students. present study is supported by minghelli et al study reporting the relation of feeling difficulty while doing physical activity with prevalence of scoliosis.8 skaggs et al. estimated the association of school bag pack and pain with activity restriction and found that the 82% of the students reported their school bags as a factor for pain, 34% were forced to restrict their physical activities due to pain and 37% stated the low back pain. however, in the same study it was found that it was the exceeding weight who caused the pain.9 sheir-ness et al, screened 1122 school students, between the ages of 12-18 years and concluded that weight of school bag packs is an important factor for causing low back pain. the back pain is mostly the consequence of wearing school bags incorrectly and it was supported by the statistical analysis which showed that such students were 1.83 times at the greater risk of developing low back pain as compared to those who used to wear their school bags correctly.10 korovessis et al, also supported the fact that carrying unequal load distribution results in the occurrence of low back pain and such students are five times more at danger of having low back pain than those who carry symmetrical loads on their back.11 the study conducted by mushtaq et al at azad jammu and kashmir findings are in are line with current finding, and reported that the weight of the bag affects students’ health negatively and backpack weight effect their gait, postures and attentiveness, students complain of aches, seems pale and may have lung and breathing problems.12. awareness campaign should be held with school management, parents and students for correct posture and allow weight bearing accordingly to age and weight prevent chronic disabilities of scoliosis and musculoskeletal pain. limitations: cross sectional is the limitation of this study as casual inferences are not established. study had the limited sample size due to short time frame conducted only in only one city, so results will not be generalized to whole population. conclusions students majority who used to wear one side shoulder bag were prone to suffer scoliosis and pain in neck and shoulder region. conflict of interest: none funding disclosure: none references 1. siddiqui os. heavy school bags and their effect on the growth of children in karachi.jictra.2016; 7(1): 55-59. 2. calloni sf, huisman ta, poretti a, soares bp. back pain and scoliosis in children: when to image, what to consider. the neuroradiology journals. 2017; 30(5):393-404. 3. abbass sj, abd-ul-amir dq. effects of backpack loads on kids posture. al-nahrain journal for engineering sciences. 2017; 1: 20(4):876-886. 4. trobisch p, suess o, schwab f. idiopathic scoliosis. dtsch arztebl int. 2010; 107(49):875-883; quiz 884. doi: 10.3238/arztebl.2010.0875. 5. tahirbegolli b, obertinca r, bytyqi a, kryeziu b, hyseni b, taganoviq b, shabani b. factors affecting the prevalence of idiopathic scoliosis among children aged 8-15 years in prishtina, kosovo. sci rep. 2021; 18:11(1):16786. doi: 10.1038/s41598-021-96398-1. 6. talasila ss, gorantla m, thomas v. a study on screening for scoliosis among school children in the age group of 10–14 using a cost effective and an innovative technique. ijcmph. 2017; 4(6):2118-2123. doi: http://dx.doi.org/10.18203/23946040.ijcmph20172187. 7. baroni mp, sanchis gj, de assis sj, dos santos rg, pereira sa, sousa kg, lopes jm. factors associated with scoliosis in schoolchildren: a cross-sectional population-based study. j 8. epidemiol. 2015;25(3):212-220. doi: 10.2188/jea.je20140061. minghelli b, oliveira r, nunes c. postural habits and weight of backpacks of portuguese adolescents: are they associated with scoliosis and low back pain? work. 2016; 7;54(1):197-208. doi: 10.3233/wor-162284. j aziz fatm med den college july – december 2022, vol. 4. no. 2 19 amna khalid et al 9. skaggs dl, early sd, d'ambra p, tolo vt, kay rm. back pain and backpacks in school children .j pediatr orthop.2006;26(3):358-363. doi: 10.1097/01.bpo.0000217723.14631.6e. 10. sheir-neiss gi, kruse rw, rahman t, jacobson lp, pelli ja. the association of backpack use and back pain in adolescents. spine (phila pa 1976). 2003; 1;28(9):922-930. doi: 10.1097/01.brs.0000058725.18067.f7 11. korovessis p, koureas g, papazisis z. correlation between backpack weight and way of carrying, sagittal and frontal spinal curvatures, athletic activity, and dorsal and low back pain in schoolchildren and adolescents. j spinal disord tech. 2004; 17(1):33-40. doi: 10.1097/00024720-200402000-00008. 12. mushtaq m, rathore s, saba m. journal effects of heavy school bags on students’ health at primary level in district haveli (kahutta) azad jammu and kashmir. development and social sciences. 2021;2 (4):456-466.doi, 10.47205/jdss.2021(2iv)39 authors’ contribution dr. amna khalid study design, concept, literature search, data collection, data analysis, first draft write-up. dr. abid rashid study design, results interpretation, supervise and critically revise all intellectual content. dr. sultan mahmood khan study concept and design, analysis, final review, overall supervision. jawad ahmad data collection statistical analysis, revised and approved the manuscript. dr. sana sarfraz study design ,data collection, second draft write up dr. sultan ayaz concept, data analysis & approved the manuscript. all authors are equally accountable for research work and integrity and approved the manuscript. date of submission: 15-08-2022 revised: 12-12-2022 accepted: 15-12-2022 9 january – june 2023, vol,5. no.1 j aziz fatm. med den college original research hypoglycemia in patients with type-2 diabetes mellitus nephropathy faheem ur rehman, sumayya rehman, iqbal haider, nayab munib, wazir mohammad khan abstract objective: to find out the frequency of hypoglycemia in type-2 diabetics having nephropathy methodology: this cross-sectional observational study was carried out in medical teaching institute khyber teaching hospital department of medicine, from august 21, 2020, to january 21, 2021. twohundred and eighty-one (281) patients with type 2 diabetic nephropathy were observed in due course and were subjected to detailed history and examination. a sample of 5 ml venous blood was obtained from the patients to measure blood glucose levels to detect hypoglycemia. experienced pathologists analyzed all investigations. results: the mean ± standard deviation (sd) of age in this study was 60± 10.26 years. female patients outnumbered males in this study. hypoglycemia was reported in 21% of patients while 79% did not have hypoglycemia. conclusion: type-2 diabetics having nephropathy are prone to hypoglycemia. these patients should be carefully observed for clinical and biochemical features of hypoglycemia. keywords: type-2 diabetes, nephropathy, hypoglycemia introduction diabetes mellitus (dm) is a protean of metabolic afflictions either due to malfunctions in insulin’s secretions, actions, or both.1 about 40% of newly developing instances of the endstage renal disease reported each year are caused by diabetic nephropathy.2 presence of persistent albuminuria, gradual glomerular filtration rate decline, and blood pressure increase are its defining features.3 defect in the counter-regulation of glucose is a significant cornerstone to the development of there is a modest impairment of the regulation of glucose. presence of chronic kidney disease hypoglycemic events in type i diabetics in contrast to type 2 faheem ur rahman, mbbs postgraduate trainee, medicine mti khyber teaching hospital peshawar, pakistan sumayya rahman, mbbs, postgraduate trainee, medicine, mti mardan medical complex mardan, pakistan iqbal haider mbbs, fcps assistant professor mti khyber teaching hospital peshawar, pakistan nayab munib, mbbs postgraduate trainee, medicine, mti khyber teaching hospital peshawar, pakistan wazir mohammad khan, mbbs, fcps professor, mti khyber teaching hospital peshawar, pakistan correspondence: dr. iqbal haider email: driqbalhaiderkth@gmail.com diabetics (t2dm), where (ckd) is an additional risk factor for patients who have diabetes. a study conducted by yun et al.; documented baseline microalbuminuria over ten years of follow-up. this feature was described as an independent risk factor for the development of severe hypoglycemia in t2dm patients with the renal function that appeared to be normal or only slightly impaired. regardless of whether they were getting insulin, this finding was documented.4 another study showed 19.1% of patients with diabetes and nephropathy had experienced one episode of hypoglycemia over follow-up.5 the objective of this research is to determine the biochemical evidence of hypoglycemia among patients of t2dm having diabetic nephropathy. owing to the increased burden of dm in our population and fatality related to ckd, patients with ckd need their diabetes to be managed effectively to prevent disease progression. methodology this cross-sectional observational study was carried out in the department of medicine, khyber teaching hospital peshawar from august 21, 2020, to january 21, 2021. open epi's sample size calculator (http://openepi.com) was used to determine the sample size, taking the population of peshawar as 4 million and 95% as the confidence level and prevalence of hypoglycemia (24%) in mailto:driqbalhaiderkth@gmail.com 10 faheem ur rehman et al january – june 2023, vol,5. no.1 j aziz fatm. med den college diabetics having kidney disease.6 the sample size is calculated to be 281.3 the sampling was done by convenience-based probability sampling. patients, including both genders, aged between 1870 years with the minimum disease (t2dm) 5 years and diabetic nephropathy, as per operational definitions, diagnosed during the last 6 months of study onset were included in this study. patients were listed as exclusion criteria having concomitant liver diseases, malignancies, or who received oral or iv glucose before presentation to the medical opd. all these eligible patients were already enrolled in the diabetic registry of the ward. they were diagnosed as having diabetic nephropathy during the last 6 months based on persistent albuminuria (>300 mg/d or >200 μg/min), progressive decline in the glomerular filtration rate (gfr), and hypertension7. these patients were brought to medical opd for a routine checkup in a fasting state to minimize the confounding bias of drug-induced hypoglycemia. their blood glucose level was checked at 8 am to minimize the confounders. after receiving an endorsement from the hospital ireb (institutional research and ethical board), the study was carried out (ref. no. 838/adr/kmc dated 23-4-2020). all patients with type-2 dm, according to the operational definition and having diabetic nephropathy with six months minimum duration and meeting the inclusion criteria were included. written informed consent was acquired from the patient or close relative in urdu. the patients were subjected to history, and clinical examination, and variable, like age, name, and gender, was recorded on a pre-designed validated questionnaire. exclusion criteria (like concomitant liver diseases, malignancies, and a recent (last week) episode of hypoglycemia) were closely adhered to prevent confounders and bias in the study's findings. experienced pathologists conducted laboratory investigations on 5ml of venous blood obtained from all patients to measure blood glucose levels. a blood glucose level ≤ 70 mg/dl will be considered hypoglycemia. statistical analysis: the spss version 20 software was utilized to analyze various data variables. mean, median, mode, and sd was calculated for quantitative variables like age, diabetes duration, duration of diabetic nephropathy, and blood glucose level. for categorical variables such as gender and hypoglycemia, percentages and frequencies were determined. effect modifiers like age, dm duration of diabetic nephropathy, and gender were addressed through stratification. pearson's chi-square test was used to test the relationship between the variables, and p <0.05 was taken as significant to either accept or reject the null hypothesis. results this study analyzes age distribution among 281 patients. patients' ages ranged from 30 to 45 years for 96 (34%) and from 46 to 70 years for 185 (66%) patients. the sd was 10.26, and the mean age was 60. the distribution of gender among 281 patients was recorded: 87 (31%) males and 194(69%) females. the analysis of the duration of diabetes among 281 patients showed 79(28%) patients having diabetes duration < 12 years and 202(72%) patients having a duration of diabetes >12 years. the mean duration of diabetes was 12 years with sd ± 10.51. the mean fasting blood glucose level was 99 mg% with sd ± 10.5 mg%. the data analyzed the duration of diabetic nephropathy among 281 patients as 93(33%) patients had a duration of diabetic nephropathy < 1 year and 188(67%) patients had a duration of diabetic nephropathy > one year. table 1: demographic variables of study participants demographics characteristics variables groups frequency percentage (%) age 30-45 years 96 34 46-70 years 185 66 gender male 87 31 female 194 69 duration of diabetes <12years 79 28 >12 years 202 72 duration of diabetic nephropathy < 1 year 93 33 >1 year 188 67 p value ≤ 0.05 is considered significant 11 hypoglycemia in patients with tdm2 nephropathy january – june 2023, vol,5. no.1 j aziz fatm. med den college p value ≤ 0.05 is considered significant the mean± sd duration of diabetic nephropathy was 4± 3.91yrs.. the frequency of hypoglycemia among 281 patients was reported as 59(21%) patients had hypoglycemia while 222(79%) patients didn't stratification of hypoglycemia with various variables like age, duration of dm, duration of diabetic nephropathy, and gender are represented in tables no. 1, 2, and 3 respectively. discussion diabetes mellitus is a pinnacle of metabolic ailments characterized by chronic hyperglycemia either due to malfunctions in insulin’s action, secretion, or both.6 metabolic abnormalities in carbohydrates, proteins, and lipids mainly result from defects in insulin regulation. diabetics from the type-2 group during the initial years of the disease are relatively asymptomatic compared to those with type 1 diabetes.7 patients with uncontrolled diabetes may be more susceptible to stupor or coma. death may be the ultimate consequence either due to ketoacidosis or non-ketotic hyperosmolar coma resulting from ineffective treatment.8 approximate ly 85% of the diabetic population is obese, a prime factor behind insulin resistance. in contrast, diabetic nephropathy accounts for 40% of all new end-stage renal disease development cases recorded annually.9 this study recorded the mean age as 60 years with sd ± 10.26. 87(31%) patients were male and 194(69%) patients were female. more than 59(21%) patients had hypoglycemia, while 222(79%) patients didn't. unfortunately, diabetes is too common in our society. poor glycemic status, early age onset, late diagnosis, and co-morbid may be the contributory factors accordingly. similar findings were reported in another study by chu yw et al., where 19.18% of patients experienced at least one episode of hypoglycemia a year before initiating dialysis.8 higher scores of adapted diabetes complications severity index (adcsi) were linked to repeated hypoglycemia in advanced diabetic kidney disease (dkd) patients (p-value ˂ 0.001). hypoglycemic events after dialysis have a profound impact on subsequent severe hypoglycemic episodes and mortality rates. one hypoglycemic episode was associated with a 15% increased risk of death and a 2.3-fold increased risk of recurrent profound hypoglycemia compared to those who had none. two or more episodes were associated with a 3.9fold increased risk of severe hypoglycemia and a 19% increased chance of death. however, the risk of myocardial infarction (mi) after dialysis was not correlated with prior severe hypoglycemia.10 another study by aghaali m et al., revealed similar findings, reporting that 38% of patients receiving glibenclamide medication and 32% of patients receiving insulin therapy experienced a minimum of one hypoglycemia incident.11 similar findings were found in a different study by moen mf et al., which showed that individuals with ckd had a greater incidence of hypoglycemia than those without ckd. 12 patients with diabetes experienced rates of ckd of 10.72 versus 5.33 /100 patient months while patients without diabetes experienced rates of 3.46 versus 2.23 / 100 patient months, respectively. at all degrees of hypoglycemia, the risks of 1-day mortality increased but attenuated in ckd patients compared to controls. adjusted odds ratios (or) for 1-day mortality from outpatient (opd) records of patients with ckd were 13.28, 7.36, and 4.34, respectively, while or for 1-day mortality from outpatient data of patients without ckd were 7.36, 4.34, and 60.12 the main limitation of this study is the singlecentered data and cross-section nature of the study. the number of previous hypoglycemic events and clinical manifestations of previously documented hypoglycemia was also not reported in this study. large multi-centered prospective cohorts are needed table 2: correlation of hypoglycemia with different demographics of study participants variable s group hypoglycemia statistics yes no chisquare (df) pvalue n % n % age in years 30-45 20 20.8 76 79.2 0.002 0.961 46-70 39 21.1 146 78.9 gender male 18 20.7 69 79.3 0.007 0.933 female 41 21.1 153 78.9 duration of diabetes <12 years 17 21.5 62 78.5 0.018 0.893 >12 years 42 20.8 160 79.2 duration of diabetic nephropat hy < 1year 19 20.4 74 79.6 0.027 0.870 >1 year 40 21.3 148 78.7 12 faheem ur rehman et al january – june 2023, vol,5. no.1 j aziz fatm. med den college for the generalization of these findings. conclusion patients with type 2 diabetes mellitus having nephropathy experienced hypoglycemia at the frequency of 21% in this study. among these patients, diabetic nephropathy was found to be predicted by older age, duration with dm since diagnosis, poor glycemic control, and nonadherence to diet, exercise, and medication. conflict of interest: none grant support and financial disclosures: none references 1. morgan m, deoraj a, felty q, yoo c, roy d. association between exposure to estrogenic endocrine disruptors polychlorinated biphenyls, phthalates and bisphenol a and gynecologic cancers, cervical, ovarian and uterine cancers. j carciong mutagen 2016; 7(6): 275-279. 2. thipsawat s. early detection of diabetic nephropathy in a patient with type 2 diabetes mellitus: a review of the literature. diab vasc dis res. 2021;18 (6): 1-9. doi:10.1177/147916412110588 56. 3. pugliese g, penno g, natali a. diabetic kidney disease: new clinical and therapeutic issues. joint position statement of the italian diabetes society and the italian society of nephrology on “the natural history of diabetic kidney disease and treatment of hyperglycemia in patients with type 2 diabetes and impaired renal function”. j nephrol 2020; 33(1): 9–35. https://doi.org/10.1007/s 40620-019-00650-x. 4. jahan s, fariduddin m, sultana n, akhtar y, hasan m. predictors of post-partum persistence of glucose intolerance and its association with cardio-metabolic risk factors in gestational diabetes mellitus. j diabetes metab 2016;6(10):609-613. 5. deepthi b, sowjanya k, lidiya b. a modern review of diabetes mellitus: an annihilatory metabolic disorder. j in silico in vitro pharmacol 2017;3(1):1-5. 6. shriraam v, mahadevan s, anitharani m, jagadeesh ns, kurup sb, vidya ta, et al. reported hypoglycemia in type 2 diabetes mellitus patients: prevalence and practices: a hospital-based study. indian j endocrinol metab. 2017; 21(1):148-153. | doi: 10.4103/2230-8210.196002 7. vecihi b, khardori r. diabetic nephropathy. medscape nov 2, 2021. https://emedicine.medscape.com/article/238946-overview. (cited on 7 dec 2022) 8. tufro a, veron d. vegf and podocytes in diabetic nephropathy. semin nephrol. 2012;32(4):385–393. doi:10.1016/j.semnephrol. 2012.06.010 9. yun js, ko sh, ko sh, song kh, ahn yb, yoon kh. presence of macroalbuminuria predicts severe hypoglycemia in patients with type 2 diabetes: a 10-year follow-up study. diabetes care. 2013;36(5):1283–1289. doi: 10.2337/dc12-1408 10. chu yw, lin hm, wang jj, weng sf, lin cc, chien cc. epidemiology and outcomes of hypoglycemia in patients with advanced diabetic kidney disease on dialysis: a national cohort study. plos one 12(3):e0174601. doi:10.1371/journal.pone. 0174601 11. alsahli m, gerich je. hypoglycemia in patients with diabetes and renal disease. j clin med. 2015;4(5):948-964. doi: 10.3390/jcm4050948 12. american diabetes association. diagnosis and classification of diabetes mellitus. diabetes care. 2014;37 suppl 1:s81–s90.doi: 10.2337/dc14-s081 13. aghaali m, saghafi h. comparing the incidence of hypoglycemia episodes in patients with type 2 diabetes and chronic kidney disease treated with insulin or glibenclamide. clin diabetol. 2018;7(3):159163. 10.5603/dk.2018.0012 14. moen mf, zhan m, hsu vd, walker ld, einhorn lm. frequency of hypoglycemia and its significance in chronic kidney disease. clin j am soc nephrol. 2009; 4(6): 1121–1127. doi: 10.2215/cjn.00800209 author’s contribution faheem ur rahman study design, data collection, manuscript writing, data analysis iqbal haider conceived and designed the study, supervise overall research work data analysis, critical revision of the manuscript for important intellectual content. sumayya rahman study design, data collection, drafted and edited the manuscript nayab munib study design, data collection drafted and edited the manuscript wazir mohammad study design, data collection, revised and approved the article all authors gave final approval for the manuscript to be published and responsible for integrity of research work date of submission: 15-01-2023 revised: 20-04-2023 accepted: 23-04-2023 https://emedicine.medscape.com/article/238946-overview j aziz fatm med den college january – june 2022; vol. 4, no. 1 6 original article antidepressant and anxiolytic effect of tramadol as compared to imipramine, in acute and chronic dosage in rats fiza soomro, nasreen kazi, aatir h. rajput, sadat memon abstract objective: to assess the anti-depressant and anxiolytic effect of tramadol as compared to imipramine (approved antidepressant) in acute and chronic doses in rats. methodology: this observational experimental animal study was carried out from december 2020 to february 2021 at liaquat university of medical and health sciences (lumhs) jamshoro in collaboration with agricultural university, tandojam. fortyeight healthy male rats housed at animal house sindh, agricultural university, tandojam after due approval from institutional ethical review board. the 48 rats were categorized into 3 equal groups of 16 each: group a for normal saline (0.9% nacl) 15ml/kg, group b for imipramine 15 mg/kg and group c for tramadol 15 mg/kg. each group was further subdivided into two groups namely acute a1, b1, c1 and chronic a2, b2, c2 and evaluated for anti-depressant and anxiety activity using forced swim test and elevated plus maze test. the data obtained was analyzed using spss. 22.0. results tramadol acted to significantly reduce the mean duration of immobility as compared to the control (p<0.001). resolution of immobility due to tramadol was insignificant when compared to imipramine. likewise, the swimming periods in the tramadol and imipramine groups were significantly longer than the control group (<0.001), but almost equal in both tramadol and imipramine groups, showcasing that tramadol has antidepressant activity at par with imipramine (p value >0.05). conclusion: tramadol exhibits significant acute and chronic antidepressant and anxiolytic effects in rats when compared to imipramine and controls. keywords: depressive disorder (major), antidepressive agents, anti-anxiety agents, tramadol, imipramine. introduction major depressive disorder (mdd), a common disorder of the mind, is characterized by a loss of pleasure or interest, depressed mood, feelings of low self-worth and exaggerated guilt, low motivation / energy, disturbances in the appetite and sleep, coupled with a sub-par concentration level. 1 the characteristic symptoms mdd may be experienced by a patient acutely or for extended periods of time (chronicity) and the symptoms may come and go (recurrent). however, one thing that remains constant is the fact that the symptoms adversely affect (invariably) the ability of an individual to deal with day-to-day responsibilities. 1 over a 121 million individuals are affected by mdd across the globe. 2 ____________________________________________________________ dr. fiza soomro 1 mbbs, mphil women medical officer dr. nasreen kazi 2 mbbs, phd professor dr. aatir h. rajput 3 mbbs, md consultant psychiatrist dr. sadat memon 4 mbbs, mphil assistant professor 1-4 liaquat university of medical & health sciences, jamshoro correspondence: dr. aatir h. rajput email: aatirh.rajput@gmail.com the world health organization (who) states that “mdd is the leading cause of disability as measured by years lived with disability (ylds) and the fourth leading contributor to the global burden of disease”. it was formerly stipulated that by 2020, mdd may attain the 2 nd position in the rank of disability adjusted life years (daly) calculated for all ages and the stipulation proved correct; as today, mdd has attained the position of the second commonest cause (for individuals aged 15 44 years) of dalys. 3 data derived from epidemiological research hints at a more prevalent distribution of mdd in the middle east, north africa, america, and south asia. 4 with 4 among the 10 countries with highest prevalence of mdd belonging to south east asia. 27% of ylds and 11% of dalys in the region are attributed to depressive disorders. a review of epidemiological studies on mdd in south asia concluded that “the prevalence in primary care is from 26.3% to 46.5%”. additionally, research stemming from pakistan during the last decade report the prevalence of mdd to range between 22% to 60%. 5 despite availability of pharmacologic therapy, the disease morbidity is much. mailto:aatirh.rajput@gmail.com j aziz fatm med den college january – june 2022; vol. 4, no. 1 7 in instances wherein the treatment is successful, and achievement of remission is noted; the depressive disorders do not cease to impose a burden. a case with remission is not guaranteed to be free from all symptoms and certain residual symptoms, particularly social dysfunction and cognitive impairment may continue to be a cause of considerable distress. 6 the risk of relapse is also everpresent, and recurrence is not rare; consequently, the quality of life in such circumstances is sub-par. a recent review reported that “the rate of recurrence of mdd treated in specialized mental health settings was very high (60% after 5 years, 67% after 10 years, and 85% after 15 years)”. 7 thus owing to the chronic nature of the condition, incomplete remission and eventual relapse, individuals suffering from mdd see no end to their suffering. 8 as stated above, because existing therapies are not sufficing, there is a great deal of unmet clinical need. 9,10 the mechanism of action of antidepressants available for commercial use is such that it brings about an increase in the serotonin levels (primarily), coupled with a hike in the norepinephrine and or dopamine levels. the hike in the levels of said chemicals exerts both acute and chronic effects. 11 thereby asserting its influence to counteract depression acutely and for extended periods of time. nonetheless, the concoctions are not devoid of complications and adverse effects such as “intolerability, delayed therapeutic effects, limited efficacy in milder depression and existence of treatment resistant depression”. this fuels the drive to continually search for safer and more potent drugs. 12,13 few of the previous studies evaluated tramadol which exhibited antidepressant activity in mice using different experimental model of depression. 14,15 if tramadol is to be proposed as a viable adjunct, more detailed animal testing must be done prior to human trials. [11] this research investigates the antidepressant and anti-anxiety effects of tramadol and compares it with imipramine (approved / commercially available anti-depressant) in forced swimming and elevated maze test animal models within 24 hours (acute dosing) and 15 days (chronic dosing). methodology this experimental animal study was the project of liaquat university of medical and health sciences (lumhs) jamshoro. it was the carried out from december 2020 to february 2021 in collaboration with agricultural university, tandojam. this project was reviewed and approved by advanced studies and research board (asrb) of lumhs (doc# lumhs /reg/acd-28265/68). sample of 48 healthy male rats were (housed at an ambient humidity and temperature, with a 12-hour light dark cycles and ample access to standard pellet and water) at animal house sindh, agricultural university, tandojam after taking due gate keeper permission. healthy male rats with normal behavior and activity weighing between 40 – 80 grams with age 3-4 months were taken while those not meeting the criteria or were previously used in other experiments were excluded. the 48 rats were categorized into 3 equal groups of 16 each: group a for normal saline (0.9% nacl) 15ml/kg, group b for imipramine 15 mg/kg and group c for tramadol 15 mg/kg. each group was subdivided into two groups namely acute a1, b1, c1 and chronic a2, b2, c2 and evaluated for anti-depressant and anxiety activity using forced swim test and elevated plus maze test. forced swim test – standard protocol rats are individually forced to swim inside vertical plexiglass cylinder (25×10×25 cm 3 ) filled with a water to a height of 15 cm. after an initial 2-minute period of vigorous activity, each animal assumes a typical immobile posture. the total duration of immobility, swimming and climbing is recorded each 2 min and total of 6 min test. duration of immobility, swimming and climbing period is compared with those of control and imipramine group. twenty-three hours after the first exposure, rats are intraperitoneally administered with drugs at a dose of 15 mg/kg at 8:00 am or 8:00 pm. control rats are administered saline. drugs is administered to the rats 40 min before conducting the study. for acute effect assessment like immobility, swimming and climbing. one hour after the administration, the fst is carried out. for the analysis of the chronic effect rats are exposed to the fst apparatus and the drug treatment is started the next day. the rats are intraperitoneally administered saline, tramadol and imipramine for 15 days. to equalize the number and the timing of the intraperitoneal injections among the groups, all rats are injected twice a day. two days after the last administration, the rats are administered drugs at a low dose (10 mg/kg) during the early light period, and 1 hour after the administration, the fst and elevated maze test is carried out. the rats are returned to their home cage after the fst and elevated maze test. elevated maze test – standard protocol: the elevated maze is a widely used behavioral assay for anxiety behavior of rats. it is easy to use, can be fully automated and valid results can be obtained in a short, 4-min (2 min for open arm and 2 min for fiza soomro et al j aziz fatm med den college january – june 2022; vol. 4, no. 1 8 closed) testing period. performa attached will be filled accordingly. following steps for elevated maze test: 1. the maze is assembled in an isolated room away from any extraneous interference of noises, scents, or movement. 2. the experimenter is restrained from making any excessive noise or movement during the entire trial and from wearing perfumes, colognes, or any product with a strong smell, since it could act as anxiety stimulus for mice. 3. illumination in the room must be measured with the aid of a lux meter, kept constant and controlled according to the analysis that is to be performed. given that low-intensity luminosity reduces open arm avoidance to analyze an anxiogenic effect low-intensity lighting (5-30 lux) should be preferred, whereas an anxiolytic effect should be analyzed under higher intensity lighting (200-400 lux or more). 4. after these experimental conditions are adjusted to a standard, the animals will be brought into the experiment room, where they will be left in their home cages for 45 to 60 min to recover from the stress of being moved. 5. clean the maze with 70% ethanol before starting the test to remove any dirt or smells accumulated on the apparatus. 6. turn on the video camera and place the first rat in the center square of the maze facing one of the open arms, preferably the one opposite to the experimenter. 7. the experimenter will stand as far away as possible from the maze and out of sight of the test animal, outside of the room if necessary. he must also avoid making unnecessary movement or sounds. 8. after 5 min of free exploration, the rat may be moved out of the maze and back into its home cage. 9. all the urine and fecal boli must be removed and the maze cleaned entirely with 70% ethanol to remove any residual smell from the first rat. afterwards, the next rat may be submitted to the test. statistical analysis: the data obtained was analyzed using spss version 22.0. shaprio wilk test was performed to confirm whether the data followed the normal distribution. data conforming to a normal distribution used as mean and standard deviation (sd). means were compared using parametric test anova. multiple comparisons were done by post hoc test. p value ≤ 0.05 indicated statistically significant in statistical analysis. results in the acute setting, the mean duration of immobility in the control group was observed to be 206.25 ± 8.0 seconds(sec), whereas it was 83.6 ± 6.5 sec and 96.1 ± 5.5 sec in the group pretreated with imipramine and tramadol (table1). in the chronic setting, similar result trends were yielded with the mean duration of immobility in the control group being 193.31 ± 8.0 sec, whereas it was 79.2 ± 2.7 sec and 80.1 ± 4.9 sec in the group pretreated with imipramine (table 2). the decrease in immobility period in the group pretreated with imipramine or tramadol as compared to control was highly significant (p value < 0.001) (table 1). table 1: mean time differences after 24 hours administering injections in acute setting a1 normal saline b1 imipramine c1 tramadol p values forced swim test mean immobility time 206 ± 8.0 83.6 ± 6.5 96.1 ± 5.5 <0.001 mean climbing time 91.82 ± 5.5 88.1 ± 3.9 91.2 ± 4.1 > 0.05 mean swimming time 91.93 ± 4.1 188.3 ± 9.7 172.7 ± 8.3 <0.001 elevated maze plus test open arm time 48.5 ± 2.1 53.2 ± 5.8 53.4 ± 5.6 >0.05 close arm time 71.5 ± 3.9 66.8 ± 4.7 66.6 ± 5.2 >0.05 p value ≤ 0.05 is taken as significant however, on multiple comparisons no significant difference was obtained between tramadol and imipramine in acute as well as in chronic settings, with p value > 0.05, showcasing that tramadol has antidepressant activity at par with imipramine (tables1and 2). table 2: mean time differences in seconds after 15 days administering injections in chronic setting a2 normal saline b2 imipramine c2 tramadol forced swim test mean ± sd mean ± sd mean ± sd p values immobility time 193.3 ± 8.0 79.2 ± 2.7 80.1 ± 4.9 <.001 climbing time 83.2 ± 3.8 92.5 ± 3.1 98.1 ± 4.2 > .05 antidepressant and anxiolytic effects of tramadol & imipramine j aziz fatm med den college january – june 2022; vol. 4, no. 1 9 swimming time 83.5 ± 3.1 188.3 ± 7.2 181.8±6.8 <.001 elevated maze plus test open arm time 49.1 ± 2.5 58.3 ± 7.1 57.9 ± 6.9 > .05 close arm time 70.9 ± 2.1 61.7 ± 6.1 62.1 ± 6.2 > .05 p value ≤ 0.05 is taken as significant current results also reveal significant increase in mean swimming time in tramadol and antidepressant group as compared to control groups after 24 hours as well as 15 days of injection administration with p value <0.001 (tables 1 & 2). likewise, the climbing time in the tramadol and imipramine groups were longer than the control group, but the difference was not found to be statistically significant (p value > 0.05). on the other hand on multiple comparison, both climbing and swimming periods in pretreated imipramine and tramadol groups are almost found to be same with p values > 0.05. in elevated maze plus test, no significant difference observed in open as well as closed arm time in both acute and chronic settings (tables 1 & 2) discussion in this study, the antidepressant-like effect of tramadol was investigated in the forced swimming test, an animal model predictive of antidepressant activity. in our experimental conditions, tramadol showed a clear inhibition of immobility latencies (antidepressant-type effect). this effect was similar to that obtained with imipramine and tricyclic antidepressant in published evidence. 16 this is endorsed by existing research that examined the neurochemical profile of tramadol and revealed that it binds to opioid receptors in the same concentration range in which it inhibits the uptake of noradrenaline and serotonin. in humans, opiates have been proved be useful in treating some forms of refractory depression. finally, several studies have documented two components in the efficacy of antidepressants as an adjuvant therapy for chronic pain. one of them is the increase in mood level that is otherwise frequently decreased in chronic pain patients; and the other is a proper anti-nociceptive effect. 17 in fact, monoamines and opioid pathways are implicated both in pain and mood. in this respect, it could be inferred from experimental studies that tramadol might add an affective (positive emotional) component to its analgesic effect. further preclinical studies are needed to explore the effect of different administration regimes and the efficacy of tramadol in other types of depression tests. 18, 19 this research only investigated the effect of tramadol in a standardized singular dosage regimen; however, others have studied the effect at different doses. one such research revealed that tramadol produced significant antidepressant effect at three different doses and that the antidepressant effect of tramadol at doses of 10 and 20 mg/kg was comparable with that of fluoxetine. published evidence also claims that the antidepressant activity of tramadol (at a dose of 40mg/kg) surpasses that of fluoxetine in animal models. 20,21 antidepressants (selective serotonin reuptake inhibitors; venlafaxine), by virtue of their property of mood elevation and increasing the level of serotonin and consequently causing inhibition of release of transmitters carrying the pain sensation from nerve endings, are efficacious in chronic pain as an adjunctive treatment. similarly, it could be inferred from our study that tramadol by acting through similar mechanism (inhibition of reuptake of monoamines leading to spinal inhibition of pain) might add moodelevation component to its analgesic effect. more preclinical studies in different antidepressant models are needed to corroborate our observations. 22, 23 mico´ and associates (2003) exposed rats to conditions that mimicked a learned helplessness model of depression. results showed that rats responded more positively to tramadol, as opposed to placebo and/or methadone. the action tramadol has on alpha 2adrenergic receptors in the brain of rats is implicated in antidepressant action because downregulation of these receptors control 5-ht and growing evidence suggests dysfunction of these receptors in depression. 24 jesse and associates (2010) conducted a study that shows evidence that the noradrenergic system, as well as dopaminergic receptors, is involved in the antidepressant effect of tramadol on mice. various alpha 2, d1, d2, and d3 receptor antagonists were coadministered with tramadol to examine alterations in the mouse brain. antagonists of those receptor sites blocked the antidepressant effects of tramadol. in conjunction, breuer and colleagues (2009) presented data of pramipexole (d3/d2 receptor agonist) and 7oh-dpat (d3 receptor agonist), having antidepressant effects in the rat model. 25 inhibition of 5-ht2c promotes release of dopamine while disinhibition reduces dopamine concentrations. 26 this study is among the only few attempts made at only gauging the anti-depressant and anxiolytic effect of tramadol but comparing it against an established agent such as imipramine and controls. the statistics yielded are largely novel and may help serve as the basis for future research. in addition to that, it identifies correlates that may serve as reliable fiza soomro et al j aziz fatm med den college january – june 2022; vol. 4, no. 1 10 supplemental treatment options in conjunction with present medications to facilitate treatment of depression. there are, however, some limitations of our study. first, we did not arrange for comparison with more drugs and just resorted to comparison with imipramine, additionally, we chose only one standardized singular dose of tramadol. furthermore, there is dearth of published evidence-based literature with which this study could be compared again intensively, thus little is known regarding how this study’s results fair other experiments. as the extent of this research was limited to a small sample size and just a singular dose of tramadol was employed, in future similar research may be carried out on a larger sample of participants with more tramadol doses being studied to further the investigation in this field. conclusion tramadol exhibits significant acute and chronic antidepressant and anxiolytic effects in rats similar to imipramine and controls. conflict of interest: the authors declare that the research was conducted in absence of any commercial or financial relationship and have no conflict of interest involved in this research source of funding: no external funding was sought or procured for this project and the enterprise was selffunded ethical statement involving animal subjects: this study involving animals were reviewed and approved by advanced studies and research board of liaquat university of medical and health sciences (lumhs) jamshoro. references 1. bray f, ferlay j, soerjomataram i, siegel rl, torre la, jemal a. kessler rc, bromet ej, de jonge p, shahly v, wilcox m. the burden of depressive illness. public health perspect depress disord. 2017;40. 2. thornicroft g, chatterji s, evans-lacko s, gruber m, sampson n, aguilar-gaxiola s, et al. under treatment of people with major depressive disorder in 21 countries. the british journal of psychiatry. 2017;210(2):119-24. 3. o'neill s. perceived helpfulness of treatment for major depressive disorder: findings from the who world mental health surveys. jama psychiatry. 2020 jan 31. 4. de aquino jp, londono a, carvalho af. an update on the epidemiology of major depressive disorder across cultures. in understanding depression 2018 (pp. 309-315). springer, singapore. 5. nishi d, imamura k, watanabe k, ishikawa h, tachimori h, takeshima t, et al. psychological distress with and without a history of depression: results from the world mental health japan 2nd survey (wmhj2). j affect disord. 2020 mar 15;265:545-51. 6. looker k. global burden of disease study 2013 collaborators. global, regional, and national incidence, prevalence, and years lived with disability for 301 acute and chronic diseases and injuries in 188 countries, 1990-2013: a systematic analysis for the global burden of disease study 2013. lancet. 2015;6736(15):606-609 7. birnbaum hg, kessler rc, kelley d, ben-hamadi r, joish vn,greenberg pe. employer burden of mild, moderate, and severe major depressive disorder: mental health services utilization and costs, and work performance. depress anxiety 2010; 27: 78–89. 8. li y, aggen s, shi s, gao j, li y, tao m, et al subtypes of major depression: latent class analysis in depressed han chinese women. psychol med 2014; 44: 3275–88. 9. ratajczak p, kus k, skurzyńska m, nowakowska e. the influence of aripiprazole and venlafaxine on the antidepressant-like effect observed in prenatally stressed rats (animal model of depression). human exp toxicol. 2018;37(9):972-82. 10. hassan u, azam n, farooq a, khan nu. prevalence of depression in medical students at rawal institute of health sciences, islamabad. pak j public health. 2018;8(1):43-7. 11. reddy ms. depression: the disorder and the burden. indian j pyschol med. 2010;32(1):1. 12. berton o, nestler ej. new approaches to antidepressant drug discovery: beyond the monoanines. nat. rev. neurosci. 2006; 7:137-151. 13. wakefield jc, horwitz av, lorenzo-luaces l. 8 chapter uncomplicated depression as normal sadness: rethinking the boundary between normal and disordered depression. the oxford handbook of mood disorders. 2017 apr 24:83.doi: 10.1093/oxfordhb/9780199973965.013.8 14. bonda c, pawar s, lokhande j. evaluation of antidepressant activity of tramadol in comparison with imipramine in swiss albino mice. int j basic clin pharmacol 2017;6:695-659. 15. kumar a, jayshree d, rajshekar st. comparative efficacy of behavior despair models in depicting antidepressant like effect of tramadol. int j basic clin pharmacol. 2013;2(6):763-767. 16. hammer-helmich l, haro jm, jönsson b, melac at, di nicola s, chollet j, et al. functional impairment in patients with major depressive disorder: the 2-year per form study. neuropsychiat dis treat. 2018 9. 17. adams gc, balbuena l, meng x, asmundson gj. when social anxiety and depression go together: a population study of comorbidity and associated consequences. j affect disord. 2016;206:48-54. 18. ramachandra k, jayalakshmi md. evaluation of antide pressant activity of tramadol in albino mice using forced swim model. int j basic clin. 2019;8(3):415. 19. bonda c, pawar s, lokhande j. evaluation of antidepressant activity of tramadol in comparison with imipramine in swiss albino mice. int j basic clin pharmacol. 2017;6:695-9. 20. picco g, masłowska a, robert a, ríos r. serotonin syndrome in advanced cancer patient treated with tramadol and antidepressants. palliative med pract. 2019;13(3):161-4. 21. barakat a. revisiting tramadol: a multi-modal agent for pain management. cns drugs. 2019;33(5):481-501. 22. olivier jd, olivier b. antidepressants and sexual dysfunctions: a translational perspective. current sexual health reports. 2019 15;11(3):156-166. antidepressant and anxiolytic effects of tramadol & imipramine j aziz fatm med den college january – june 2022; vol. 4, no. 1 11 23. saxena pp, bodkin ja. opioidergic agents as antidepressants: rationale and promise. cns drugs. 2019;33(1):9-16. 24. mico, ja, berrocoso, e, sanchez-blazquez, p, garzon j. opiates as antidepressants. curr pharmaceutical des. 2009;15(2):1612–1622. 25. jesse cr, wilhelm ea, bortolatto cf, nogueira cw. evidence for the involvement of the noradrenergic system, dopaminergic and imidazoline receptors in the antidepressant-like effect of tramadol in mice. pharmacol biochem behav.2010;95(3):344-350. 26. barber j. examining the use of tramadol hydrochloride as an antidepressant. exp clin psychopharmacol. 2011;19(2):123. author’s contribution: fiza soomro study design, acquisition of data and manuscript writing. revised and approved the articles. study design, acquisition of data and manuscript writing. revised and approved the articles. nasreen kazi study design, acquisition of data and manuscript writing. revised and approved the articles aatir h. rajput sadat memon study design, data analysis and interpretation and write up of results. revising manuscript critically for important intellectual content. study design, acquisition of data, data analysis and interpretation, revised and approve the manuscript all authors are equally accountable for accuracy, integrity of all aspects of the research work. fiza soomro et al date of submission: 15-09-2021 revised: 05-01-2022 accepted: 09-01-2022 july december 2019; vol. 1, no. 2 j aziz fatm med den clg 79 case report exogenous caesarean scar pregnancy; a diagnostic challenge raheela farhat ch, rooha tariq abstract caesarean scar ectopic pregnancy is a pregnancy in which the ectopic is in the scar tissue of a previous caesarean section. this is a life threatening condition if proper diagnosis and management does not take place in time. it is not compatible with a successful pregnancy. the clinical diagnosis can be obscure, especially in the initial stages; therefore clinicians should be acquainted with the sonographic hallmarks of caesarean scar pregnancy on radiographic. it is very similar to a spontaneous abortion in progress which is why the misdiagnosis is common. we present a case of caesarean scar pregnancy which was managed by performing an emergency laparotomy. keywords: caesarean scar pregnancy, ectopic pregnancy, hysterectomy. introduction caesarean section scar ectopic pregnancy is a rare event with a high risk of hemorrhagic shock, disseminated intravascular coagulation and the need of emergency lifesaving hysterectomy. here we describe a case of ectopic gestation in a previous caesarean section scar which was initially misdiagnosed as “spontaneous abortion in progress”, which resulted in uncontrollable bleeding which required an emergency laparotomy. case report a 31 year old woman, g6p2a3, was admitted to aziz fatimah hospital, faisalabad with the complaint of vaginal bleeding, cramping and lower abdominal pain. she had an amenorrhea of 8 weeks gestation. she also had a caesarean section for failure to progress in labour in her first pregnancy 7 years ago. this was followed by three first trimester termination of pregnancies at 8 weeks of gestation for which an evacuation was done. the second baby was delivered through cesarean section. on receiving, she was haemo-dynamically stable. on general physical examination, pulse was 90/min; bp was 100/60mmhg. ____________________________________________________________ dr. raheela farhat ch (mbbs, mcps, fcps) associate professor of obstetrics & gynaecology aziz fatimah medical & dental college, faisalabad dr. rooha tariq (mbbs) demonstrator aziz fatimah medical and dental college, faisalabad correspondence: dr. raheela farhat ch email: areebafarhat@yahoo.com on abdominal examination, no significant finding was there; abdomen was soft and non-tender. on vaginal examination, cervical os was open and fresh blood was oozing through the vagina. a trans-vaginal ultrasound was done by a professional. it showed a non-viable intrauterine pregnancy in the anterior lower uterine segment (lus) with a gestational age of about 8 weeks. all of a sudden the patient began to bleed profusely. after initial resuscitative measures, all the baseline investigations (complete blood count, random blood glucose, renal function tests, liver function tests, coagulation profile, and viral markers) were sent. it was decided to shift the patient to operation theater for evacuation. the patient was given spinal anesthesia and per speculum examination was done. the cervical os was patulous and the bleeding through the os was moderate. throughout the procedure there was inrush of fresh blood resulting in hemodynamic compromise. figure 1: a bulging mass seen, arising from the scar site in the uterus mailto:areebafarhat@yahoo.com july december 2019; vol. 1, no. 2 j aziz fatm med den clg 80 four units of blood were arranged on emergency basis and the patient’s vitals were constantly monitored. on p/v examination, it felt that the placenta is attached to the scar site of old caesarean section. a diagnosis of scar pregnancy became clear. patient’s family was counseled and taken consent for an emergency laparotomy. the diagnosis of ectopic pregnancy in previous caesarean section was confirmed. the placenta was adherent to the scar. the gestational sac and placenta were removed from the scar which was then excised and repair of uterus was done. three units of blood were transfused in the operation theatre and the patient remained vitally stable throughout the procedure. the patient was discharged three days after her laparotomy. there was no abnormal uterine bleeding in the follow up. discussion ectopic pregnancy is a pregnancy in which there is implantation of ovum in an unusual site. caesarean scar pregnancy (csp) is a type of ectopic pregnancy which results in implantation of ovum in the previous caesarean scar. this accounts for 6.1% of all ectopic pregnancies and 1 in 1800-2200 pregnancies. better imaging techniques and understanding of this disease has led to an increase in the diagnosis of caesarean scar pregnancy.1,2 placenta accreta and csp are histologically similar, other than caesarean section history, there are not enough risk factors established for this condition. ultrasound is extremely helpful for diagnosis csp within its early stages, with a sensitivity of 86.4% and a specificity of 92.3%. adherences to a customary set of diagnostic criteria could facilitate us in understanding and diagnosing this case as soon as possible with the minimal harm done to the patient. csp sometimes presents as a heterogeneous mass, containing cystic-solid, or mixed echoes among the caesarean scar or lower female internal reproductive organ section.3 late diagnosis of csp has detrimental effects like scar rapture and massive hemorrhage. thereby, early diagnosis and intervention is important to minimize the risk of these complications from arising.1,2,3 csp is of two types on the basis of ultrasound findings; type 1 (endogenic csp) and type 2 (exogenic csp). type 1 is distinguished by amniotic sac protrusion into the uterine cavity and cervico-isthmic space. type 2 is characterized by implantation which bulges towards serosa, 4mm less from the bladder wall. type 1 is less severe, with chance of progression to full term but with a high risk of massive haemorrhage. our patient presented with type 2 exogenous csp. ultrasound is a powerful tool in order to make decisions and formulate individual management plan on the basis of myometrium thickness, sac location, perfusion and gestational age.2 csp often presents with abdominal pain, abnormal vaginal bleeding and an increased level of beta hcg, leading to a misdiagnosis of an early miscarriage.5 in csp, the gestational sac appears well perfused, whereas in spontaneous abortion in progress, the gestational sac is seen in the cervical canal and the sac appears avascular. in csp, there is a decidual reaction surrounding the gestational sac which indicates implantation in scar area and not the retained products. if the patient is stable and csp is suspected, then magnetic resonance imaging (mri) or an interval ultrasound can be used to reach the diagnosis. mri with contrast enhancement is helpful in a better diagnosis of csp in 95.5% of cases in comparison to 88.6% with normal ultrasound. despite the high accuracy in diagnosis, the use of mri is limited due to prolonged acquisition time. it is pivotal to have early diagnosis and prompt treatment of csp in order to have better, safer and less invasive management options for the patient with less chances of complications along with a decreased chance of endangering the fertility of the patient.2,7 treatment persistent or massive vaginal bleed, delay in treatment and diagnosis along with failure of preservation of fertility lead to hysterectomy in csp patients. approximately 2 to 12.5% csp results in hysterectomy. another management option is bilateral uterine artery ablation (uaa). it leads to lesser haemorrhage along with less progression to hysterectomy. however, uaa cannot be employed in each case due to its unavailability or when the patient has excessive bleeding. ultrasound usage is significant as it allows the ultrasound guided administration of embryocidal agents directly into the sac. this form of local treatment is extensively practiced and it proves to be effective in reducing systemic therapy as well as reducing the need for hysterectomy. ultrasound itself can be used as an embryocidal agent with the help of high intensity focused ultrasound. this technique uses the heat energy which is directly focused at the sac which stops the cardiac activity and results in a rapid fall of hcg level.3 weekly hcg coupled with weekly to monthly ultrasounds can be used as follow up to see its raheela farhat ch et al. july december 2019; vol. 1, no. 2 j aziz fatm med den clg 81 author’s contribution: dr. raheela farhat ch provided all material for case report. accountable for given information. dr. rooha tariq manuscript writing. resolution since no proper protocol has been set for this condition. transvaginal ultrasound is 100% sensitive and specific for the detection of defects in the caesarean scar with the help of salinsonohy stereography. to summarize, csp is a very rare condition which requires proper attention and protocols to reduce the risk of complications. csp must be considered a viable diagnosis in patients with vaginal bleed and abdominal pain by the clinicians and the sonographers; the consequences of a missed diagnosis are detrimental. this may form the basis for advising women on the spacing of subsequent pregnancies after a cesarean delivery. fortunately for our patient, the right diagnosis was made after initially being mistaken for spontaneous abortion in progress. so this highlights the difficulty in differentiating between csp and spontaneous abortion and hence the importance of high index of suspicion in women with risk factors. conflicts of interest: none. references 1. collins k, kothari a. catastrophic consequences of a caesarean scar pregnancy missed on ultrasound. australas j ultrasound med. 2015;18 (4):150–156. doi: 10.1002/j.2205-0140.2015.tb00222.x 2. winder s, reid s, condous g. ultrasound diagnosis of ectopic pregnancy. australas j ultrasound med. 2011;14 (2):29–33. doi:10.1002/j.2205-0140.2011.tb00192.x 3. huang l, du y, zhao c. high‐intensity focused ultrasound combined with dilatation and curettage for cesarean scar pregnancy. uog 2014; 43 (1): 98–101. 4. bij de vaate aj, naji o, witmer m, veersema s, brölmann ha, bourne t, huirne ja. prevalence, potential risk factors for development and symptoms related to the presence of uterine niches following cesarean section: systematic review. ultrasound obstet gynecol 2014; 43 (4): 372–82. 5. li y, xiang y, wan x, feng f, ren t. (clinical study on 39 cases with caesarean scar pregnancy with sonographic mass). chinese. 2014; 49 (1): 10–13. 6. timor‐tritsch ie, monteagudo a. unforeseen consequences of the increasing rate of cesarean deliveries: early placenta accreta and cesarean scar pregnancy. a review. am j obstet gynecol 2012; 207 (1): 14–29. 7. osborn da, williams tr, craig bm. cesarean scar pregnancy: sonographic and magnetic resonance imaging findings, complications, and treatment. j ultrasound med 2012; 31 (9): 1449–1456. caesarean scar pregnancy 25 january – june 2023, vol,5. no.1 j aziz fatm. med den college original research prevalence and purpose of medical app usage in pakistan: a cross-sectional study ibtehaj munir, farhat ijaz, kanza waqar, iman hussain, rana khurram aftab, asim zia abstract objective: to determine the prevalence and purpose of medical app usage in pakistan. methodology: a cross-sectional study was conducted using a pretested form, distributed via google forms. convenience sampling was used to select a sample of 357 mbbs, bds, allied health, and nursing students of cmh lahore medical college. data was analyzed using “spss version 23.0”. descriptive statistics were calculated as frequencies. a “p-value” of less than 0.05 was deemed statistically significant results: out of all the participants (357), 40.3% were males, and 59.7% were females, with an average age of 20.89 ± 1.61. 95.5% of the participants used intelligent devices, and 86.6% were aware of the medical apps available for use on mobiles. a majority (64.1%) of the students had various medical apps installed on their phones. almost half of these students (45.1%) were advised by medical educators to use different medical apps for their studies. most of the students made use of medical apps to search for medical information (49.7%), followed by exam preparations (37.6%), revision (34.6%), and preparation of presentations (26.4.%). the use of general clinical textbooks and clinical skills guide apps were 22.2% and 23.9%, respectively. 20.5% of the participants did not use medical apps for any purpose. a likert scale showed that students think that medical apps are easy to obtain, and many of them frequently use them too. they believe that these apps save time during clinical practice. medscape was the most common app being used (29.3%), followed by gray’s anatomy (25%) and pharmapedia (23.9%). conclusion: the common usage of medical apps was recurrent amongst medical students. keywords: medical apps, medical students, smartphones introduction conventionally the primary medium for obtaining education for students was textbooks1; however, with passing the time and advancements in technology, there has been an increase in the tools available to acquire information with mobile ibtehaj munir, mbbs house officer cmh lahore medical college & institute of dentistry, lhr, pakistan farhat ijaz, mbbs, mphil associate professor cmh lahore medical college & institute of dentistry, lhr, pakistan kanza waqar, mbbs house officer cmh lahore medical college & institute of dentistry, lhr, pakistan iman hussain, mbbs cmh lahore medical college & institute of dentistry, lhr, pakistan rana khurram aftab, mbbs additional medical superintendent services hospital lhr, pakistan asim zia, mbbs, msc assistant professor continental medical college, lahore correspondence dr. farhat ijaz email: farhatkhurrumrana@cmhlahore.edu.pk phones and applications (apps) replacing the traditional settings of acquiring knowledge.2the world's earliest smartphone was launched in 1994, and the portion of individuals using smartphones have been steadily increasing since then.3 hence, innovative mobile technology has penetrated deeply into society in a relatively short period, attracting a range of subscribers ranging from school going children to senior citizens.4 smartphone applications and the internet have introduced a recent wave of approachability and flexibility within academic processes.5 a similar trend can be seen in medical education, as it was shown that smartphones are a valuable educational aid for medical students4. greater than 13,000 mobile applications associating to health under the headings of "medical" and "healthcare and fitness" are available on different app stores.4 medical students are using smartphone applications for many purposes, including guidelines for clinical setup, medical calculators, drug reference tools and other decision-support aids, textbooks, and literature search portals.6,7,8 numerous apps cater to 26 ibtihaj munir at el january – june 2023, vol,5. no.1 j aziz fatm. med den college multiple subfields of medicine, while others are used for mere ease and convenience and to decrease the paper load. for example, some apps can simulate surgical procedures and operations. in contrast, others can be used to assess various sensory functions of the body, such as hearing and visual tests, and other apps are used as an alternative to constantly buying and carrying a load of new edition textbooks as medical applications by way of technology are constantly being updated with apt information.9,10 these apps can further help healthcare workers to remember their appointments, provide reference ranges for multiple systems of the body, count calories and count the body mass index without applying much manual labor.11 various research on the use of mobile phones and applications in supporting medical students has been undertaken worldwide, and as data suggests, intelligent devices were deemed beneficial to 84% of medical students in the united kingdom. 8. another study conducted at monash university, melbourne, australia, stated that 76% of students using smartphones used medical applications. similar results were obtained at a canadian university where 65% of students utilized a medical application to access clinical texts and pharmacological references.12 however, a discrepancy was seen in pakistan, where one study suggested the frequency of usage of these smartphone apps was 71%, 2while another stated it was 41.46%, so there was a difficulty in understanding the prevalence observed in this region.13 there has been very little research focused on this topic in pakistan to reflect upon the benefit of medical phone applications amongst medical students despite smartphones' fair use and popularity in the medical setup. so the current study was designed to explore the knowledge and perception regarding medical apps among participants, and to determine the prevalence of medical app usage in pakistan, and the purpose for which they are used. methodology a cross-sectional analysis was conducted on "cmh lahore medical college" students from january to july 2021 after taking informed consent. students of all years from mbbs, bds, nursing, and allied health sciences were part of the study. a convenience sampling method was used. a sample size of 306 was calculated using the who equation: “n = z2 x p x (1 p) / e2” where: z = 1.96 for a confidence level (α) of 95% p = proportion (expressed as a decimal), e = margin of error. we got 357 responses just to be on the safer side. the data were collected utilizing a pretested, selfdesigned questionnaire. the questionnaire was comprised of three main parts. the first portion of the questionnaire asked questions on demographic data like age, gender, year, the field of study, whether or not to use a mobile device, having medical apps installed on the smart device, and the intent of installing the applications. the second portion was focused on the students' perceptions of medical apps on smartphones. the third portion aimed to see the importance of medical applications in clinical practice. the fourth portion asked about the students' use of various medical applications and aimed to identify the prevalent applications among them. five options were given to the students in the second part of the questionnaire, from which they could select only one from the following: strongly agree, agree, neutral, disagree, or strongly disagree. statistical analysis the information collected was analyzed using “spss version 23.0”. descriptive statistics were calculated as frequencies. a “pvalue” of less than 0.05 was deemed statistically significant. the "ethical review committee of cmh lahore medical college" provided ethical approval. results out of all the participants (357), 40.3% were males, and 59.7% were females, with a combined mean age of 20.89 ± 1.61. 95.5% of the participants used intelligent devices, and 86.6% were aware of the medical apps available for use on mobiles. a majority (64.1%) of the students had various medical apps installed on their phones. almost half of these students (45.1%) were advised by their medical educators to use different medical apps for their studies. (table `1) most of the students used medical apps for looking up medical information (49.7%), followed by exam preparations (37.6%), revision (34.6%), and preparation of presentation 27 prevelance purpose of medical app usage january – june 2023, vol,5. no.1 j aziz fatm. med den college (26.4.%). the use of general clinical textbooks and clinical skills guide apps were 22.2% and 23.9%, respectively. 20.5% of the participants did not use apps for any purpose. (table 2) all of the items in tables 3 and 4 were scored on a likert scale, and the average and standard deviations for each response were determined. 1 stood for strongly agree, whereas five stood for strongly disagree. table 5 represents the apps used by the students. medscape was the most common (29.3%), followed by gray's anatomy (25%) and pharmapedia (23.9%). table 6 shows the apps most frequently used in each medical year. table 1: demographic data and characteristics of participants parameters frequency percentage total participants 357 100 gender male 144 40.3 female 213 59.7 using smart devices yes 341 95.5 no 16 4.5 awareness about the availability of medical apps on smart devices yes 309 86.6 no 48 13.4 have medical apps installed on your smart devices yes 229 64.1 no 128 35.9 have your medical educators ever recommended that you obtain a specific medical app for your mobile? yes 161 45.1 no 196 54.9 table 2: purpose of use of medical apps parameters frequency percentage revision 123 34.6 preparation of presentations 94 26.4 lookup medical information 177 49.7 medical journals 50 14 during ward rounds 43 12.1 medical news 53 14.9 medications/drug guide 64 18 exam preparations 134 37.6 general clinical textbook 79 22.2 clinical skills guide 85 23.9 i do not have medical apps 73 20.5 other purpose 2 0.6 total 977 100 table 3: students' perceptions about medical apps on smart phones parameters mean (total score 5) st. deviation medical apps are easy to obtain 2.25 1.10 i am looking to obtain more apps in future 2.37 1.08 i would recommend the use of apps to my fellow medical students 2.27 1.06 i do most of my medical learning using medical apps 3.38 1.24 medical apps are essential tools for undergrad students 2.62 1.02 medical apps are superior to medical books 3.61 1.13 medical apps are as good as medical books 3.31 1.07 medical apps are inferior to medical books 2.81 1.03 medical apps can replace medical books 3.66 1.17 medical apps can supplement medical books 2.59 1.17 medical apps provide helpful medical information at the point of care 2.45 0.95 free medical apps are inferior in quality compared to paid apps 2.52 1.01 no dangers in using medical apps for patient care 2.91 0.94 table 4: students' perceptions of the impact of medical apps on clinical practice parameters mean (total score 5) st. deviation improve clinical decision making 2.58 0.19 save time 2.12 0.88 allows faster access to national clinical practice guidelines 2.26 0.93 allows faster access to common laboratory reference values 2.24 0.93 helps in making differential diagnosis 2.41 0.96 perform useful medical-related calculations 2.39 0.94 allows faster access to reliable sources of medical knowledge 2.35 0.99 allows faster access to reliable sources of clinical skills 2.44 0.95 allows accurate medicine dosage calculations 2.61 0.94 allows more straightforward medicine dosage calculations 2.48 0.93 allows faster access to evidencebased medical practice 2.54 0.92 28 ibtihaj munir et al january – june 2023, vol,5. no.1 j aziz fatm. med den college discussion the recent advancements in technology have completely shifted the way we view the world today. smartphones have played a significant role in that. the medical field has also seen change due to the new technology available now. smart devices have become a significant part of our lives, as can be seen from the findings of our research, which show that about 95.5% of participants own a smart device. these results are similar to another study conducted in pakistan, which showed that around 95.8% of participants own a smart device 15, and another study conducted at “king abdulaziz university,” jeddah which had a result of 99%.16. in recent years, medical applications have increased in popularity among medical students; however, the results show a varying level of interest among students worldwide. in our study, around 86.6% of participants were knowledgeable about medical apps on their phones, and around 64.1% had various medical apps installed on their phones. this result is less than the results obtained from other studies conducted at king abdulaziz university, jeddah 16, and monash university17, where around 76% and 89.1% of participants had one or more medical apps installed on their phones. 45.1% of these pupils had put applications on their phones on the recommendation of their medical educator. this is greater than the result seen in a study conducted at monash university, which resulted in 32%.17 in our current study, the primary use of medical applications was for looking up medical information (49.7%), followed by exam preparation (37.6%) and revision (34.6%). the results were similar to those gathered in other studies, with looking up medical information and revision being the most common use.16,18 20.5% of students were not using any kind of medical applications, and these results were comparable to another study conducted in pakistan in 2019, which had a percentage of 28% .19 students who were using medical applications agreed that medical apps were easy to access, and they demonstrated a desire to achieve medical apps in the future; however, most students did not agree that medical applications can take the role of medical textbooks (table 3). in clinical practice, students believe that using apps saves time and allows in clinical settings, quicker availability of healthcare information (table 4). conclusion in our study, around majority of participants were knowledgeable about medical apps on their phones, and half of participants had various medical apps installed on their phones. despite the increased level of interest and the shift of the students towards elearning, grant support and financial disclosure: none conflict of interest: none references 1. tez m, yildiz b. how reliable are medical textbooks?. j. grad. med. educ. 2017;9(4):550-554. doi:http://dx.doi.org/10.4300/ jgme-d-17-00209.1 table 5: medical apps used by students parameters number percentage medscape 103 29.3 pharma guide 44 12.5 pharmapedia 84 23.9 geeky medicine 65 18.5 gray’s anatomy 88 25 uptodate 13 3.7 oxford handbooks 37 10.5 medcalc 20 5.7 anatomy atlas 40 11.4 teachmeanatomy 21 6 dr. najeeb's lectures 14 4 sketchy 3 0.9 i do not use any apps 45 12.8 other apps 45 12.8 table 6: most frequent medical app used by each year year of study medical app name percentage 1st year gray’s anatomy 34.9 2nd year gray’s anatomy 36.3 3rd year pharmapedia & medscape 32.7 4th year medscape 44.8 5th year medscape 80 http://dx.doi.org/10.4300/%20jgme-d-17-00209.1 http://dx.doi.org/10.4300/%20jgme-d-17-00209.1 29 prevelance purpose of medical app usage january – june 2023, vol,5. no.1 j aziz fatm. med den college 2. hisam a, shafique mu, khurshid mn, hamza a, asad mb, shakeel t. usage and types of mobile medical applications amongst medical students of pakistan and its association with their academic performance. pak. j. med. sci. 2019; 35(2):432436. doi: 10.12669/pjms.35.2.672. 3. boulos mn, wheeler s, tavares c, jones r. how smartphones are changing the face of mobile and participatory healthcare: an overview, with example from ecaalyx. biomed. eng. online. 2011; 10 (1):1-4. doi: 10.1186/1475-925x-10-24. 4. koh kc, wan jk, selvanathan s, vivekananda c, lee gy, ng ct. medical students' perceptions regarding the impact of mobile medical applications on their clinical practice. journal m t m. 2014;3(1):46-53. doi: 10.1111/medu.13131. 5. al-hariri mt, al-hattami aa. impact of students' use of technology on their learning achievements in physiology courses at the university of dammam. j taibah univ med sci. 2017;12(1):82-5. doi: 10.1016/j.jtumed.2016.07.004. 6. mosa as, yoo i, sheets l. a systematic review of healthcare applications for smartphones. bmc med. inform. decis. mak. 2012;12(1):1-31. doi: 10.1186/1472-6947-12-67 7. kalra n, singh p. smartphone and medical related app usage among physiotherapy students of delhi. i r j e t. 2017;4(5):1411-1414. 8. payne kf, wharrad h, watts k. smartphone and medical related app use among medical students and junior doctors in the united kingdom (uk): a regional survey. bmc med. inform. decis. mak. 2012; 12(1):1-1. doi: 10.1186/1472-694712-121. 9. o’neill km, holmer h, greenberg sl, meara jg. applying surgical apps: smartphone and tablet apps prove useful in clinical practice. a c s. 2013;98(11):10-8. doi:1033928/014774 47-20111021-37. 10. murfin m. know your apps: an evidence-based approach to evaluation of mobile clinical applications j physician assist educ. 2013; 24(3):38-40. doi: 10.1097/01367895-20132403000008. 11. low d, clark n, soar j, padkin a, stoneham a, perkins gd, et al. randomised control trial to determine if use of the iresus© application on a smart phone improves the performance of an advanced life support provider in a simulated medical emergency. anaesth. 2011;66(4):255-262. doi:10.1111/j.13652044.2011.06649.x. 12. chatterley t, chojecki d. personal digital assistant usage among undergraduate medical students: exploring trends, barriers, and the advent of smartphones. journal of the medical library association:j med libr assoc.2010;98(2):157-160.doi: 10.3163/1536-5050.98.2.008. 13. shah j, haq u, bashir a, shah sa. awareness of academic use of smartphones and medical apps among medical students in a private medical college. j pak med assoc. 2016;66 (2):184-186. doi: 10.1016/j.jiph.2016.08.006. 14. robinson t, cronin t, ibrahim h, jinks m, molitor t, newman j, et al. smartphone use and acceptability among clinical medical students: a questionnaire-based study. j med syst. 2013; 37(3):9936. doi: 10.1007/s10916-013-9936-5 15. shah j, haq u, bashir a, shah sa. awareness of academic use of smartphones and medical apps among medical students in a private medical college. j pak med assoc.. 2016; 66(2):184-186. 16. sayedalamin z, alshuaibi a, almutairi o, baghaffar m, jameel t, baig m. utilization of smart phones related medical applications among medical students at king abdulaziz university, jeddah: a cross-sectional study. j infect. 2016;9(6):691-697.doi: 10.1016/j.jiph.2016.08.006. 17. koehler n, yao k, vujovic o, mcmenamin c. medical students’ use of and attitudes towards medical applications. journal m t m.2012; 1(4):16-21. 18. payne kf, wharrad h, watts k. smartphone and medical related app use among medical students and junior doctors in the united kingdom (uk): a regional survey. bmc med. inform. decis. mak. 2012;12()11-11. doi: 10.1186/1472-694712-121. 19. hisam a, shafique mu, khurshid mn, hamza a, asad mb, shakeel t. usage and types of mobile medical applications amongst medical students of pakistan and its association with their academic performance. pak. j. med. sci. 2019; 35(2):432436. doi: 10.12669/pjms.35.2.672. author’s contribution ibtehaj munir study design, data collection, data analysis and interpretation revise and approve the article farhat ijaz study design, data collection, data analysis and interpretation, revise all intellectual contents and approve the article kanza waqar study design, data collection, manuscript writing, revised and approve the article iman hussain study design, data collection revise and approve the article rana khurram aftab study design, manuscript writing revise and approve the manuscript asim zia study design, data collection revise and approve the article all authors are equally accountable for accuracy, integrity of all aspects of the research work. date of submission: 20-07-2022 revised: 12-03-2023 accepted: 13-03-2023 https://doi.org/10.1186/1475-925x-10-24 https://doi.org/10.1111/medu.13131 https://doi.org/10.1016/j.jtumed.2016.07.004 https://doi.org/10.1186/1472-6947-12-67 https://doi.org/10.1186/1472-6947-12-121 https://doi.org/10.1186/1472-6947-12-121 https://doi.org/10.1097/01367895-201324030-00008 https://doi.org/10.1097/01367895-201324030-00008 journal.cdr original article effect of inter-pupillary distance on stereo-acuity fatima iqbal, komal atta, hashim ali khan, amna iqbal abstract objective: to determine the effect of interpupillary distance (ipd) on stereopsis and to compare this affect in male and female population. methodology:descriptive cross-sectional study was conducted on 30 individuals of either gender with age ranging from 15 to 30 years. sample was recruited by non-probability convenient sampling technique at ophthalmology department of madina teaching hospital, faisalabad from august 2018 to december 2018. individuals with any ocular pathology, un-corrected refractive error or drug users were excluded. near ipd was measured using millimeter scale and stereopsis was evaluated using titmus fly test. data was analyzed by spss21. p value ≤0.05 was considered significant. results:our study comprised of 30 subjects of aged range 15-30 years. 15 participants were male and 15 were females. ipd values for both genders were ranged between 62 – 66 mm. mean ipd was 65± 1.01 mm for male and 64.8± 1.14 mm for female ,no significant difference was observed in mean ipd among gender ( p value = 0.41) by t test. both male and females have high ipd and low depth of perception (< 40 sec of arc), no significant difference in levels of stereopsis was noted among gender (p value= 0.36). pearson's correlation showed significant relation between ipd and stereopsis. (p value= 0000*). conclusion:we found higher ipd and low depth of perception among both genders. key words:depth perception, inter-pupillary distance, stereopsis. introduction depth perception. there are different factors contributing to the threshold of three-dimensional vision. there are many factors that affect the stereoacuity. these factors are age, gender, vergence movements and displaying 2, 3 distance from the target. inter pupillary distances (ipd) 5 is the distance between the centers of the two pupils. it determines the stereo separation of the two images which are combined in the brain to produce stereo visualization. 5 ipd is affected by gender, race and age. normative mean values for ipd reported by the recent past pakistani studies are 60 to 63 mm for adults age ranged between 155,6 30 years. ipd values higher in males as compared to 6 females. similar values are also documented by iranian 7 study. closer to these values turkish study reported, 59 to 61 mm ipd values in turkish population with approx. 8 2mm higher in males as compared to females. recent past study conducted in karachi comparing the ipd among the various ethnicities of pakistan reported longer ipd in punjabi and balochi ethnicities than sindhi community, most probably due to broader skeletal frame 5 of formers. shafiee d and his colleagues reported that males have approx. 2 mm wider ipd than females and 4 females have higher depth of perception. these results showed inverse relation between ipd and stereopsis. osunwoke ea, study was also documented lower interpupillary distance with high stereopsis scores in 9 women than in men. on contrary to above studies, eom y and his coauthors reported improvement in stereoacuity 10 with increase in ipd. ipd jafmdc jan-june 2019;vol.1, no.1 fatima iqbal lecturer school of optometry, the university of faisalabad .dr. komal atta assistant professor the university of faisalabad hashim ali khan consultant optometrist sehhat foundation hospital , gilgit dr.amna iqbal, research internee, university of virginia usa corresponding author: fatima iqbal: email: fatima.iqbal@uf.edu.pk stereopsis is believed to be the only powerful cue to depth perception. horizontal retinal image disparity between the two points of the retina or extra-foveal 1,2 points fuse to give a three dimensional image. best single stereoscopic vision with depth perception are 3 due to the fusion of disparate images. stereo-acuity is best obtained when image is formed on non4 corresponding points. stereoacuity is a measure of the binocular visual function and it helps to judge the relative distances between the objects. distance can affect stereopsis when visual system is incorporated with accommodation, convergence and cognitive 4 factors. in stereopsis different image sizes or disparities are used by the optical system to obtain 4 depth perception. these differences become larger as when viewing a particular object at the earliest distance. each human eye has a certain threshold for 33 ipd and stereo-acuity statistical analysis data analysis was done using spss 21. quantitative variables like age and ipd values are presented as means and compare by ttest. categorical variables like and gender is presented as frequency and compare by chi square test. pearson correlation was used to assess the relation between ipd and stereopsis. p value ≤0.05 was considered significant. results study comprised of 30 subjects of aged range 15-30 years. 15 participants were male and 15 were females. ipd values for both genders were ranged between 62 – 66 mm. mean ipd was 65± 1.01 mm for male and 64.8± 1.14mm for female, no significant difference was observed in mean ipd among gender( 0.41) by t test. on analyzing the frequency of subjects with increase and normal ipd values we found that off 15 males, 14 had longer ipd ranging from 64 mm to 66mm and only 1 had normal ipd ranging from 62mm to 63mm. off total females 11 had increased ipd ranging from 64 mm to 66mm and only 4 had normal ipd ranging from 62mm to 64mm. both genders have similar frequencies of longer ipd no significant difference was found in this respect (p value 0.142) (table 1). interestingly, we found low depth of perception in both genders. 13 males had less depth (< 40 sec of arc) whereas 2 had more depth with (> 800 sec of arc). 11 females had less depth (< 40 sec of arc) whereas 4 had more depth with (>800 sec of arc) no significant difference in levels of stereopsis was noted among gender (p value 0.36) (table 2). our results show that the majority of the study population of both genders has longer ipd with low depth of perception. figure 1 is showing that the both genders have low levels of stereopsis. figure 2 is indicating that the subjects with higher ipd have low depth of perception and worsen sterioacuity. pearson correlation shows significant inverse relation between the stereopsis and ipd (p values 0.000*). plays a key role in the optical industry for properly dispensing glasses as it determines the depth perception by stereoscopically separating the two points perceived 1 by the brain to produce the three-dimensional vision. in ideal spectacles, center of the ophthalmic lenses should coincide with the visual axis that passes from the center of pupils or equivalent to the ipd of a person for 1 obtaining better stereoacuity. spectacle non-tolerance and prismatic effect is induced due to the decentration of the ophthalmic lenses and causes the distortion of 1 stereopsis. exact relationship between the ipd and stereopsis is required to be elucidated to aware the opticians about the prismatic effect over stereopsis and consider ipd while dispensing glasses for quality vision. materials and methods descriptive cross-sectional study was conducted at ophthalmology department of madina teaching hospital and the university of faisalabad from august 2018 to december 2018. 30 healthy individuals of either gender of 15 to 30 years were recruited through nonrandomized convenient sampling technique. individuals with un-corrected refractive errors, any past ocular and surgical history, strabismus, anisometropia, amblyopia, tropias, phorias and any systemic diseases affecting the vision were excluded. ethical approval from institute and consent was taken from each subject according to declaration of helsinki. visual acuity was tested from lcd snellen's at 6 meter distance. anterior and posterior segment of eye was also evaluated. distance between two pupils was measured using a millimeter rule. we set a normal range of near ipd from 62 to 63 millimeters (normal range of ipd was taken from previous pakistani studies). individuals were asked to grab the ruler and to ensure a proper measurement, holding the ruler right above their eyes. examiner sited at a distance of 20 centimeter from the subjects, they were asked to close their right eye while looking to examiner's nose with opened eye and holding the zero mark of millimeter ruler right above the exact center of persons left pupil. then measure the distance of right pupil by opening the right eye and found the exact millimeter mark that fell on subject's right pupil. the numbers in millimeters that lines up with the center of subjects' pupil were noted. to measure stereopsis titmus fly test was used. each subject was asked to wear the 3-d polaroid glasses and to look at a vectogragh that consisted of two plates in the form of booklet and appreciate the 3-d figure at a distance of 40 centimeters. the amount of disparity in images was measured in sec of arc and it was varied as 400-100 sec of arc and 800-40 sec of arc within the test target. fatima iqbal et al. 34jafmdc jan-june 2019;vol.1, no.1 table 1: interpupillary distance (ipd) among gender (n= 30) gender (n=30) interpupillary distance (ipd) total (30) normal ipd (62mm to 64mm) increase ipd (66 mm to 67mm) frequency (n) frequency (n) male (15) 1 14 15 female (15) 4 11 15 p value 0.142 2 comparison by x test, statistically significant value at p < 0.05 ipd and stereo-acuity conflicting to this eom y,et al documented the high depth of perception and improvement in stereoacuity with 10 increase in ipd. however this link is yet to be clearly elucidated. the purpose of this study is to explore the relationship between stereopsis and ipd and to compare this among the gender. we tried to prove that size of the ipd has a significant effect on stereopsis. we achieved this by using range 40-800 seconds of arc of titmus fly test. concerning the difference among the gender with respect to ipd (p=0.142) and stereopsis (p =0.361) nonsignificant difference was observed, but interestingly we found higher ipd and low depth of perception among both gender. ipd measurements of the majority of current study population were ranged between 64mm to 66 mm among both genders, which are approx. 2±1 mm, higher 5,7,8,11 than other pakistani, iranian and turkish studies. pakistani study by hayat n etal and alkhairy s etal reported mean ipd of ranged 60 to 62mm, with higher 5, 6 values in males as compared to females. hayat n also reported the higher ipd values in punjabi population than sindhi community, this is in agreement of our findings as we found higher ipd in our population than studies 5 conducted in karachi sindh. iranian study also reported 7 the mean ipd of 61 to 63 mm in iranian population. our results proved that there is significant relationship between ipd and stereopsis (p=0.000*). we found that with increase in ipd, depth of perception decreases resulting in poor sterioacuity. our results are supported by shafiee d etal who also reported the significant association between ipd and stereopsis. shafiee d etal found that the subjects with high ipd have low depth of 4 perception and worsening in sterioacuity. on contrary to our results, the same author documented the significant difference in ipd and stereopsis among the gender and found smaller ipd and high depth of perception among the females as compared to males. another study conducted in turkey also reported mean ipd values among males were 2 mm ± 1.58 mm higher than that in 8 females. ipd measurements have significant role in optical industry. ignorance of ipd during the dispensing of eyeglasses results in the poor image quality caused by marginal astigmatism, spherical aberration and chromatic aberration. stereopsis is very important for a c c o m m o d a t i o n w h i l e p e r f o r m i n g n e a r t a s k s , convergence and near focusing become harder because of the increased ipd. opticians should be aware about the induced prismatic effect over stereopsis and consider ipd while dispensing glasses. we recommend that eye professionals must evaluate this factor while prescribing glasses and performing stereoacuity tests for improving the quality of vision. discussion this study was conducted to highlight the importance of interpupillary distance (ipd) and to explore its relation with stereopsis. ipd is the component of stereopsis which can influence stereoacuity. evidences are available showing that people with smaller ipd can perceive depth in longer distance in contrast the individuals with larger 4 ipd. it was also supported by few researches that females 4,11 have smaller ipd and better stereoacuity than males. fatima iqbal et al. 35jafmdc jan-june 2019;vol.1, no.1 figure 1: graphical representation between gender and stereopsis table 2: stereopsis among the gender (n=30) gender (n=30) stereopsis less depth (< 40 sec) more depth ( > 800 sec of arc ) total (30) frequency (n) frequency( n) male (15) 13 2 15 female (15) 11 4 15 p value 0.361 2 comparison by x test, statistically significant value at p < 0.05 figure 2: graphical relationship between ipd and stereopsis. ipd and stereo-acuity 5.hayat n, alkhairy s, cheema a, ehsan m, khan ma normal interpupillary, inner canthal distance and outer canthal distance in a normal population of pakistan. pak j med sci.2019;35(1):50-54. 6.alkhairy s, siddiquie f, hassan m. orbitofacial anthroprometry in a pakistani population. pak j ophthlmol. 2016; 32(1):41-47. 7.fesharaki h, rezaei l, farrahi f, banihashem t, jahanbakhshi a. normal interpupillary distance values in an iranian population. j ophthalmic vis res. 2012; 7: 231–4. 8.yildirim y, ibrahim sahbaz ,kar t. evaluation of interpupillary distance in the turkish population. clinical ophthalmology . 2015; 9:1413-16. 9.osunwoke ea, didia bc, olotu ej, yerikema ah. a study on the normal values of inner canthal, outer canthal, interpupillary distance and head circumference of 3-21 years ijaws. am. j. sci. ind. res., 2012, 3(6): 441-445. 10.eom y, song js, ahn se, kang sy, suh yw, oh j, kim sh, kim hm effects of interpupillary distance on stereoacuity: the frisby davis distance stereotest versus a 3-dimensional distance stereotest.jpn j ophthalmol. 2013;57(5):486-92. 11.usman ym, shugaba al. the interpupillary distance and the inner and outer canthal distances. e3 j sci res. 2015;3(1):001-003. https://pdfs.semanticscholar.org/a1d1/29b0947f7c514d 648f2cea15be514ded62f7.pd. conclusion we found higher ipd and low depth of perception among both genders. a broader scale researches are required to establish the exact relationship between ipd and stereopsis. limitation smaller sample size is the limitation of the study. similar studies on larger scales should be conducted to evaluate the association between ipd and stereopsis. conflict of interest:there is no conflict between authors and financial disclosures. funding source : none references 1.arshad a , choudhry aa, hussain sj, latif i, kalasra a.effect of spectacle centration on stereoacuity. journal of rawalpindi medical college (jrmc); 2017; 21(2): 117-121. 2.aslankurt m, aslan l, aksoy a, et al. laterality does not affect the depth perception, but interpupillary distance. journal of ophthalmology.2013; 48(1):1-5. kim. 3.sh, suh yw, yun c, yoo e j, yeom jh, cho ya. influence of stereopsis and abnormal binocular vision on ocular and systemic discomfort while watching 3d television eye (lond). 2013; 27(11): 1243–1248. 4.shafiee d, jafari ar, shafiee aa. correlation between interpupillary distance and stereo acuity. bull. env. pharmacol. life sci. 2014; l 3 (12): 26-33. fatima iqbal et al. 36jafmdc jan-june 2019;vol.1, no.1 author`s contribution fatima iqbal: study design, data collection, manuscript , writing, revise and approved the manuscript. dr. komal atta: study design, data collection, result interpretation, write up of manuscript, editing and formulation of tables, revise and approve the manuscript. hashim ali khan: study design, supervise throughout the research, manuscript writing, revise all the contents and approve the manuscript. dr. amna iqbal: study design, data analysis, and interpretation of results, editing and formatting the manuscript. reviewed and approved the manuscript. page 31 page 32 page 33 page 34 journal.cdr case report a rare presentation of central giant cell granuloma of the maxillary sinus muhammad saleem, danish hassnain abstract objective: central giant cell granuloma (cgcg), also known as giant cell reparative granuloma, is a non-cancerous proliferative lesion of unknown aetiology. it is a localized osteolytic lesion with the diverse biological behavior of aggression which most commonly affects the mandible and other jaw bones. it is a rare condition and its characteristic clinical or radiological features are still not well defined. it resembles to some neoplasms and can easily be misdiagnosed with antrochoanal polyp, angiofibroma, squamous cell carcinoma and inverted cell papilloma. we are reporting a case of rare presentation of cgcg arising from the maxillary sinus. this is a case report of a 15 year old boy who presented with the episodes of recurrent epistaxis and nasal obstruction. diagnosis of giant cell granuloma was made on the basis of age presentation, rare location, and histological findings of excised specimen, which revealed central giant cell granuloma. this case helps to demonstrate the wide variation in the clinical and radiological features of cgcg and highlights the significance of histological features of this lesion. key words: central giant cell granuloma, recurrent epistaxis, nasal obstruction. introduction expansion of cortex, displacement of teeth, or root 11 resorption can be found radiographically. still characteristic radiographic and clinical signs are not well defined and it can be misdiagnosed for various malignant and non-malignant conditions. hence, the diagnosis of cgcg solely depends on histopathology. histologically, cgcg is characterised by vascular connective tissue and osteoclastic natured multinucleated giant cells and 11 spindle shaped collagenized stromal cells. the cells are evenly dispersed and clustered around haemorrhagic 14 areas. histologically, the tumour also consists of vascularized network of stromal cells and multinucleated giant cells meagrely interspersed with collagenous fibrils but in contrast to cgcg, it shows irregular and uneven distribution with presence of plump tumour cells in 13,15 stroma. this is verified by the case reported here that is presented with clinical features which lead to differential diagnosis from antro-choanal polyp, angiofibroma, squamous cell carcinoma to inverted cell papilloma. the 15 last two mentioned are unlikely. case report a male patient 15 year of age was referred from gojra to faisal hospital peoples colony faisalabad with history of recurrent severe epistaxis and nasal obstruction for last one year. on examination there was whitish blog of secretions in the left side of nasal cavity giving the impression of nasal polyps. on posterior rhinoscopy the mass was seen occupying left choana. intra oral examination shows pushing of the soft palate anteriorly and there was no swelling over the palate or sub-labial region. no numbness or paresthesia over the cheek was noted and there is no loosening of the teeth of upper jaw. apart from this, rest of the ent examination was unremarkable. the patient also gave the history of frequent hospital admissions with the complaints of intractable epistaxis for which he got the treatment frequently in the form of jafmdc jan-june 2019;vol.1, no.1 dr.muhammad saleem assistant professor ent and head neck surgery dept. aziz fatimah medical college faisalabad. dr.danish hassnain registrar ent and head neck surgery dept. aziz fatimah medical college faisalabad. corresponding author: dr.muhammad saleem email:drsaleementspt@yahoo.com c e n t r a l g i a n t c e l l g r a n u l o m a ( c g c g ) i s a n interosseous lesion comprising of fibrous tissue which is believed to have many foci of haemorrhages, collections of multinucleated giant cells and often 1,2 trabeculae of woven bone. cgcg is a non-cancerous proliferative lesion of unknown cause which most commonly involves mandible and rarely maxilla with 1,3 infiltrating giant cells cgcg is considered local reparative reaction of bone due to its destructive 4 nature. intramedullary haemorrhage or trauma are the 5 possible contributing factors. giant cell granuloma though owing a benign course is often confused with giant cell tumour. however for giant cell tumour distinguishing factor is its occurrence in ages of 25 to 1,6 45 years. moreover, giant cell tumour usually involves long bones which recurs even after curettage showing the aggressiveness of the tumour and its 7,8 potential for malignant transformation. cgcg has a lower recurrence rate and no cases of malignant 9,10 transformation or metastasis has been reported. clinical presentation of cgcg of the mandible is variable and difficult to predict. depending on the clinical and radiological features, it is categorized as 11 nonaggressive and aggressive lesion. usually, the central lesions present with no signs and symptoms clinically other than a diffuse swelling over the affected 11,12 area. unilocular or a multilocular radiolucent lesion with diffuse or irregular borders, sometimes leading to 37 giant cell granuloma of maxillary during surgery. almost 2 pints of blood loss was noted. inverted cell papilloma and squamous cell carcinoma were less likely diagnosis considering the young age of the patient, clinical presentation of severe epistaxis, origin of the lesion from maxillary sinus and growing towards the nasopharynx, duration of the lesion and intra 15 operative findings. a diagnosis of cgcg was achieved by histopathological report of the excised specimen. histopathological report reveals spindle ovoid to round histocytes with well vascularized fibrous stroma and woven bone lined by osteoclast, suggestive of giant cell lesion. all this morphology and age of the patient favours central giant cell granuloma. nasal packing off and on. at that time there were two possibilities. one of them was antrochoanal polyp and the other was angiofibroma. the unlikely possibilities considered were squamous cell carcinoma and inverted cell papilloma. the patient was advised ct-scan and routine examinations including cbc, bleeding profile and lfts. on ct scan there was an extensive lesion in the maxillary sinus which was widespread, breaching the medial wall of maxillary sinus and occupying the nasal cavity and approaching toward the nasopharynx. we planned excision using trans-antral approach. the intrao p e r a t i v e fi n d i n g s f a v o u r e d t h e d i a g n o s i s o f angiofibroma as there was massive bleeding muhammad saleem et al. 38jafmdc jan-june 2019;vol.1, no.1 figure 1: mass removed from nasal cavity and maxillary sinus. figure 2: ct scan coronal view giant cell granuloma of maxillary monocyte-macrophages) within a prominent fibrous 11 stroma. evidences shows multinucleated giant cells 15 exhibiting characteristics of the osteoclasts phenotype. these findings are in favour of our reported case as we found almost similar histological findings. our histopathology report of excised specimen reveals collections of spindle ovoid to round histocytes with well vascularized fibrous stroma. woven bones lined by osteoclast were also noted in specimen of the patient. our report concludes giant cell rich lesion. all morphological changes favour central giant cell granuloma. these characteristic features of cgcg were also reported by 1,11,14 previous researches. in most of the cases this granuloma presents as a single, painless radiolucent expansion. some lesions are seen to be more devastating 18 even on surrounding bones. the management of cgcg depends upon presentations of the lesion and on radiographic findings. generally, curettage is done for localized and well-defined lesions with a low rate of 18,19 recurrence. in widespread lesions, which involves cortex perforation on radiographs, radical excision and partial maxillectomy is inevitable. adjunct to surgery, medical management includes steroids or calcitonin that is believed to inhibit the function of giant cells and halt 18,19 the osteoclastic activity. however, alpha interferon appears to be fruitful for managing aggressive cgcg 17 due to its anti-angiogenic effects. alpha interferon also encourages bone formation through stimulation of osteoblasts and pre-osteoblasts and inhibit bone 19 resorption. intravenous bisphosphonates are given on 19 priority basis with hopeful results. follow-up at regular interval is mandatory to rule out any occurrence. recurrences are rare and are more common in the 18 maxilla. presentation of this lesion is quite variable and c h a l l e n g i n g f o r d i a g n o s i s . s o w e r e c o m m e n d considering cgcg in the differential diagnosis of the growths of the maxillary sinus. in our case the clinical findings and behaviour is quite different resembling the antrochoanal polyp and angiofibroma. conclusion diagnosis of cgcg should be made on the basis histopatholical findings, as clinical and radiological features are widely varied among patient to patient. author contribution all authors contributed equally and are responsible for material provided. conflict of interest and funding disclosure they have no conflict of interest and funding support. references 1.hosur mb, puranik rs, vanaki ss, puranik sr, ingaleshwar ps. clinicopathological profile of central discussion central giant cell granuloma is believed as a noncancerous proliferative condition whose etiology is still not known, however evidences are available showing it 1,2 can be secondary to trauma. it commonly develops in in children and young adults aged less than 30 years with 16 more predilection in females than males. central giant cell granuloma occurs in any of the facial bones and cranial vault. most common presenting site for this 1 7 granuloma is mandible and rarely in maxilla. mandibular granuloma usually presents infront of right sided first molars and is seen often to cross the midline. the clinical presentation of cgcg is not uniform and it 16 has an unpredictable course. it is believed to be quite variable ranging from asymptomatic slow growing painless swelling with noticeable facial asymmetry, to aggressive nature of the lesion that manifests with 2,11,17 pain. alternatively, this finding can be disclosed accidentally while doing jaw radiography for other purposes. palpation of the suspected bony area may elicit tenderness. teeth may lose their firmness to the point of 11 attachment but maintain their vitality. the present case, however, involved the maxilla. maxillary cgcg is likely to present with asymptomatic facial swelling as the cortical bone here is thin and provides little resistance to growth. similar report of maxillary cgcg was reported by tsichlaki a in 2012. tsichlaki a reported the presence of maxillary cgcg in a 45 years old female, who 17 presented with five months history of nasal obstruction. the age of presentation was unusual as it is more 16 common in first three decades of life. we reported the presence of cgcg in 15 years old boy, who presented with episodes of recurrent epistaxis and nasal obstruction for 1year. on the bases of the presenting age, rare location and histological features of the specimen of patient we diagnosed it as cgcg. kapoor r reported a case of maxillary cgcg in 2016. he reported the case of maxillary cgcg in 20-year-old female patient presenting with swelling of the left side of the face for 1-year. our report and previous reports discussed above are showing the wide variation in the clinical features of patients of cgcg. a diagnosis of giant cell granuloma should depend upon histological features as the radiological pictures cgcg presentation is also not uniform. it appears from unilocular or to multilocular on 11,16 radiographs. it may be well-defined as well as can be poorly defined and can show variable expansion with 11 damage to cortical plate. case reported by chavva s, shows ill-defined borders with evident cortical 11 destruction and migration of associated teeth. the radiological appearance of the lesion cannot be considered as diagnostic for granuloma solely as it can be confused with many other lesions of jaw. hence, the 9 ultimate diagnosis depends upon histopathology. histologically giant cell granulomas show numerous multinucleated giant cells and mononuclear cells ( fi b r o b l a s t a n d h i s t i o c y t e l i k e c e l l s a n d muhammad saleem et al. 40jafmdc jan-june 2019;vol.1, no.1 giant cell granuloma of maxillary 11.chavva s, dhawalraj c, badam rk, chaitanya nc. aggressive central giant cell granuloma: a rare case report. j indian acad oral med radiol 2017;29:220-2. 12. kurra s, reddy d s, gunupati s, k s, reddy m s.fibrous dysplasia and central giant cell granuloma: a report of hybrid lesion with its review and hypotheticated pathogenesis.j clin diagn res. 2013 may;7(5):954-8. 13. al sheddi ma , mosadomi ha, al dayel fh. central giant cell granuloma of the jaws and giant cell tumor of long bones:a clinicopathological, cytometric and immunohistochemical comparative study. s j oral sci vol .2014;1(1): 47-53. 14. liu b, yu sf, li tj. multinucleated giant cells in various forms of giant cell containing lesions of the jaws express features of osteoclasts. j oral pathol med 2003;32:367. 15. but-hadzic j, jenko k, poljak m, kocjan bj, gale n, strojan p. sinonasal inverted papilloma associated with squamous cell carcinoma.radiol oncol. 2011 dec;45(4):267-72. doi: 10.2478/v10019-011-0033-4. 16. cavalcante rc e al. central giant cell granuloma ( c g c g ) i n c h i l d h o o d : s u rg i c a l t r e a t m e n t b y maintaining. rsbo. 2017;14(1):37-43. 17. tsichlaki a, george k, manisali m. an unusual presentation of a maxillary central giant cell granuloma. j surg case rep. 2012 1; 2012(8):7. doi: 10.1093/jscr/2012.8.7. 18. kapoor r, karjodkar fr, sansare k, dora ac. an unusual case of maxillary central giant cell granuloma. indian j oral health res 2016;2:55-8. 19. chawla c, rao pk, kini r,etal. central giant cell granuloma: a case report. a j diagn imaging. 2017;2. giant cell granulomas: an institutional experience and study of immunohistochemistry expression of p63 in central giant cell granuloma. j oral maxillofac pathol 2018;22:173-9. 2.baskaran p, gopal m, rastogi v, misra sr. aggressive central giant cell granuloma of the mandible, a diagnostic dilemma. j oral maxillofac radiol 2015;3:88-91. 3. de lange j,van den akker hp.clinical and radiological features of central giant-cell lesions of the jaw. oral surg oral med oral pathol oral radiol endod. 2005 apr;99(4):464-70. 4. shah u a, shah a k, kumar s. giant cell reparative granuloma of the jaw: a case report. indian j rdiol imaging 2006;16:677-8. 5. stavropoulos f, katz j. central giant cell granulomas: a systematic review of the radiographic characteristics with the addition of 20 new cases. dentomaxillofac radiol. 2002 jul;31(4):213-7. review. 6. haque au, moatasim a.giant cell tumor of bone: a neoplasm or a reactive condition?int j clin exp pathol. 2008 jan 1;1(6):489-501. 7. deshmukh g, beg s. giant cell tumor of bone in northern india-incidence, clinical presentation, radiology, histopathology and treatment approach. indian journal of public health research and development.2013:4(2):215. 8. singh a, chawla n, chawla sp. giant-cell tumor of bone: treatment options and role of denosumab. dovepress. 2015;9 : 6974. 9. priyadharshini ki, thiruneervanan r, mohanbabu v, kumar pr. an unusual presentation of aggressive central giant cell granuloma. journal of advanced clinical and research insights. 2014;1(2):53-6. 10. manekar vf. aggressive central giant cell granuloma of mandible transformed to an enormous vascular lesion. journal of oro facial research. 2012;2(4):243-246. muhammad saleem et al. 41jafmdc jan-june 2019;vol.1, no.1 giant cell granuloma of maxillary muhammad saleem et al. 39jafmdc jan-june 2019;vol.1, no.1 figure 3a: histopathology slide showing giant cell granuloma features. fig. 3b: histopathology report of the specimen shown in fig. 2. page 35 page 36 page 37 page 38 page 39 journal.cdr original article attributes of an effective clinical teacher in undergraduate medical education: students' perspective noor-i-kiran naeem , haris iqbal , wajid butt abstract background:a good clinical teacher constitutes one of the major factors towards providing quality educational environment in the wards for medical students. modern era has opened new domains for defining methods for clinical teaching as well as new roles for a clinical teacher. this study aims at exploring medical student' perspectives regarding attributes of an effective clinical teacher. methods: this mixed method study involved final year mbbs students of aziz fatima medical and dental college, faisalabad from august 2018 to november 2018.seventy-five medical students filled the nursing clinical teacher effectiveness inventory (nctei) questionnaire after taking informed consent. this was followed by seven individual face to face interviews of students consenting for interview. results:most important attribute for an effective clinical teacher was reported having good interpersonal skills (95.2%) followed by having skills of evaluation( 90.7%) , clinical competence( 84.7%) , good personality traits (83.2%) and teaching skills(81.1%).students felt it most important to have a teacher who is approachable and with whom they can communicate easily. conclusion:in the present era of medical education, an undergraduate medical student expects his clinical teacher to be approachable, professional, a positive role model with good interpersonal and teaching skills. key words: attributes, clinical teacher, undergraduate medical teacher. introduction studies have demonstrated diversity of roles that a 3-5 clinical teacher plays in a medical student's life. not only a does a clinical teacher act as a knowledge and resource provider for the students, he also acts as a 4 facilitator in learning along with role model for students. study conducted by cruess s et al demonstrated the role of positive role modeling of clinical teachers in a medical 5 student's life. positive role modeling can also lead to future career choices of medical students. the role of clinical teacher has further diversified with the advent of technology, opening new domains for defining the attributes of an effective clinical teacher which need to 7 be explored. this study aims at exploring medical student's perspective of attributes of an effective clinical teacher in context of pakistani setting. material & methods objective the primary aim of this study was to explore the perspectives of final year mbbs students regarding attributes of a good clinical teacher. research question what is the perspective of medical students regarding attributes of a good clinical teacher? study design this mixed method study employed the sequential explanatory design in which quantitative data was interpreted by using qualitative results. the study was jafmdc jan-june 2019;vol.1, no.1 dr. noor-i-kiran naeem , assistant professor aziz fatimah medical and dental college, faisalabad dr. haris iqbal , consultant ophthalmologist dr. rehmatullah hospital, gojra dr. wajid butt, art coordinator australian concept centre, lahore, correspondence: dr. noor-i-kiran naeem email: noorikiran@yahoo.com undergraduate medical and allied health professional education aims at providing theoretical knowledge along with clinical experience in order to prepare the students for a professional role in domains including medicine, nursing and allied health sciences. the clinical exposure provided to these undergraduate .1 students is paramount in acquiring new clinical skills .clinical rotations in various disciplines prepare a medical student to apply his theoretical knowledge through critical thinking and clinical decision making 2 and develop related clinical skills. teaching at bed side has been known to build not only clinical skills of the students but also enhance their values of medical ethics, professionalism as well as interpersonal 3 skills. role of clinical teachers remain paramount in this regard as they can facilitate the students by providing best possible learning experience in each clinical scenario. time and again, multiple studies have 14 attributes of an effective clinical among the two genders to find out any statistical differences between the two groups by applying t-tests with significance level of 0.05. for qualitative analysis, atlas ti software was used to organize and analyze the data. the answers to open ended questions from the questionnaire were analyzed, coded and ranked into categories as described by the students. similarly, the interviews were transcribed and analyzed through atlas ti after member checking. open coding was performed and themes generated via priori coding according to the conceptual framework (taking the nctei questionnaire categories). inter-coder reliability was ensured during the process. results out of hundred medical students, seventy-five returned the study questionnaire making response rate of 75%. table 1 shows the demographics of the participants involved. interpersonal skills” was reported to be on the top of the list for a good clinical teacher, followed by evaluation, having clinical competence personality traits, and finally teaching skills. the table 2 shows the ranking of five main categories as perceived by students. the data was also organized to see separate responses from each gender. (table 3) none of the categories were found significantly different among the genders. ta b l e 1 : d e m o g r a p h i c s o f p a r t i c i p a n t s re t u r n i n g questionnaires ( n = 75) conducted at aziz fatimah medical and dental college, faisalabad, over a period of four months from august 2018 to november 2018. sampling technique was purposive involving final year mbbs students of aziz fatimah medical and dental college, faisalabad. participation was voluntary in the study. data collection data collection tools used in the study was survey questionnaire followed by individual semistructured interviews. mixed method research allowed the researcher to get an overview of the issue under research through survey followed by in-depth discussion of the research topic through interviews. after taking permission from the colleges institutional review board and institutional ethical c o m m i t t e e , t h e n u r s i n g clinical teacher effectiveness inventory (nctei) was distributed among hundred final year mbbs students. the nctei is a validated inventory with 47 items from five categories having reliability coefficients 0.89 for teaching, 0.84 for nursing competence, 0.82 for evaluation, 0.86 for interpersonal relationship, and 0.83 for personality. each item utilize a seven point likert 8 scale. an open ended option to include student's response regarding any additional attribute(s) of a good clinical teacher was also provided. the participants were also asked to rank the categories from being “most important” to “least important.” this was followed by in-depth individual, semistructured interviews of seven consenting participants. the interviews aimed at clarifying the reasons for additional traits in the open ended question and to discuss the most highlighted characteristics through the i n v e n t o r y. a n o n y m i t y a n d c o n fi d e n t i a l i t y w a s maintained throughout and informed consent was taken from the participants. data analysis descriptive statistics were used to analyze demographic variables and determine the attributes of a good clinical teacher as perceived by medical students. the nctei questionnaire with its 48 teaching behaviors was ranked on a seven-point scale from 1 (never important) to 7 (always important). mean scores were calculated for each behavior. in mean scores, higher scores showed more effective characteristics of a good clinical teacher. a comparison of means was then used to examine and rank the students, perceptions for five main categories of teaching ability, interpersonal relationship, personality traits, clinical competence, and evaluation. category scores were obtained by summing scores of all items within a category. category score was also compared noor-i-kiran et al. 15jafmdc jan-june 2019;vol.1, no.1 number of participants (n=75 ) percentage (%) gender male 34 45% female 41 55% age ( in years) 24 years 26 35% 25 years 45 60% 26 years 4 05% table 2: student's ranking of clinical teacher attributes ( n=75) ranking of clinical teacher attributes’ category from most important to least important possible score range mean + sd ratio proportion from maximum score minimum maximum 1 interpersonal skills 7 42 40.0 + 4.49 95.2% 2 evaluation 8 56 50.8 + 6.29 90.7 % 3 clinical competence 9 63 53.35 + 6.88 84.7 % 4 personality traits 7 49 40.8 + 5.94 83.2 % 5 teaching skills 7 119 96.55 + 9.59 81.1 % attributes of an effective clinical similarity to our study where students have reported effective teaching skills as a part of attributes of an effective clinical teacher. more studies on teachers' perspective on an effective clinical teacher have been 11,12 done by nidhi et al and gary et al. according to nidhi et al , teachers agreed on competencies like effective teaching skills, providing learning environment and rolemodelling to be possessed in order to teach medical 11 students. similarly, dawn e. and eli b. highlighted recognizing student abilities and good communication skills to be present for facilitating physiotherapy 13 students. when discussing about ranking these attributes, most important attribute for an effective clinical teacher in our study was reported to have good interpersonal skills. this is in contrast to previous studies done that showed an effective teacher should demonstrate good teaching skills 3 , 4 , 8 a l o n g w i t h a d e q u a t e c l i n i c a l c o m p e t e n c e . furthermore, studies done on medical education focused more on knowledge building role of teacher in contrast to studies related to nursing and other allied health 14 sciences. for instance, chulani etal discussed the attributes like enhancing team work along with knowledge to be pivotal and most important in a clinical 14 teaching. this was in congruence to our study, though the role of developing skills of team work had been mentioned during interviews by students when they discussed about interpersonal skills. our results demonstrated a striking difference with many of the previous studies by ranking interpersonal skills as most important attribute for a clinical teacher. an explanation can be proposed that with evolving technology and improving standards of medical education, the role of a medical teacher has evolved with time. the generation of today, commonly known as the “millennial”, is linked to each other via various modalities like internet and social media. they have grown to be in a virtual environment which is accessible to them at any time. similarly, when talking about attributes of a teacher, all medical students agreed on the teacher being approachable and available to them if they needed. a study done in japan also demonstrated similar attribute of a medical teacher to have approachability and being able 12 to provide sufficient support along with teaching skills. similarly, our study also demonstrated that students wanted a teacher who is approachable and who can provide effective feedback on their performance. limitations and future directions this study was limited to a single, private medical school following a traditional curriculum. future directions could include multi-institutional input with comparison between public and private sectors as well as between those with integrated and traditional teaching, keeping in mind, the changing trend in educational psychology for the millennials.attributes of clinical teacher from individual departments may also be explored and table3:comparison of male and female student's responses in various categories for a good clinical teacher. ( n=75) noor-i-kiran et al. 16jafmdc jan-june 2019;vol.1, no.1 note: the means and standard deviations reported here were calculated from a seven-point response set where 1 = not at all descriptive, 7 = very descriptive. statistically significant at p value < 0.05 student's interviews validated the ranking of attributes as reported from the questionnaire. students reported that an e f f e c t i v e c l i n i c a l t e a c h e r “ s h o u l d a l w a y s b e approachable.” student 5 stated: “there may be thousands questions in my mind that occur during ward rotation or in opd, but i cannot find a teacher free and available to answer those for me. it is understandable that they are busy but they should also be there for us.” another aspect that was put forward by students was demonstrating good professional behavior and providing positive role modeling. student 6: “if a teacher cannot give patient or attendant due respect, how can we feel comfortable with him?” having good communication skills was reported by all the students as an important attribute of an effective clinical teacher. student 1: “we would like to go to a teacher who explains to us the topics clearly….” students further elaborated the role of a clinical teacher in “pointing out important topics for examinations” as well as “correcting the clinical methods of the students by giving feedback on performance.” when asked about clinical competence, student 2 replied,” i am always inspired by the teacher who is clinically competent as this was what i want to be in future.” students commented about general personality traits when talking about attributes of a good clinical teacher. student 1: “i would like to go to a teacher who handles things in a methodical manner and schedule teaching for us.” discussion this research aimed at studying the students' perspectives about an effective clinical teacher. most reported attributes for a clinical teacher have been studied in detail by various researchers. jahan etal demonstrated in their study that the most important characteristic which a teacher should possess 9 was knowledge. most studies had been performed by taking views of various stakeholders like students, teachers and nurses. gary et al emphasized on students' opinions in their literature review about teachers having knowledge along with clinical competence to provide an 10 effective learning experience to students. this is in attribute of a good clinical teacher male n=34 female n=41 p value mean sd ratio mean sd ratio teaching skills 94.5 10.12 98.6 9.06 0.068 clinical competence 52.4 7.24 54.3 6.52 0.2360 evaluation 51.0 6.26 50.6 6.32 0.7848 interpersonal skills 40.3 4.75 39.7 4.23 0.5648 personality 41.2 5.12 40.4 6.76 0.5719 attributes of an effective clinical [internet].2008; 336(7646):718–21. http://www.ncbi.nlm.nih.gov/pubmed/18369229. 7.alhaqwi ai, taha ws. promoting excellence in teaching and learning in clinical education. j taibah univ med sci [internet]. 2015; 10(1):97–101. http://www.sciencedirect.com/science/article/pii/s1658 36121500027x#bbib17. 8.knox je, mogan j. important clinical teacher behaviours as perceived by university nursing faculty, students and graduates. j adv nurs. 1985; 10(1):25–30. 9.jahan f, sadaf s, kalia s, khan a, hamza h bin. attributes of an effective clinical teacher: a survey on students'and teachers'perceptions. j coll physicians surg pakistan.2008;18(6):357–61. 10.sutkin g, wagner e, harris i, schiffer r. what makes a good clinical teacher inmedicine? a review of the literature. acad med. 2008; 83(5):452–66. 11.huff ng, roy b, estrada ca, centor rm, castiglioni a, willett ll, et al. teachingbehaviors that define highest rated attending physicians: a study of the residentperspective. med teach. 2014; 36(11):991–6. 12.kikukawa m, nabeta h, ono m, emura s, oda y, koizumi s, et al. the characteristics of a good clinical teacher as perceived by resident physicians in japan: a qualitative study. bmc med educ. 2013; 13(1). 13.ernstzen d, e b. the roles and attributes of the clinical teacher that contribute to favourable learning environments: a case study from physiotherapy. south african j physiother. 2012; 68(1):9–14. 14.herath c, zhou y, gan y, nakandawire n, gong y, lu z. a comparative study ofinterprofessional education in global health care: a systematic review. medicine.2017 sep96(38):7336. compared for similarities and differences. perspectives of faculty as well as patients and administrative staff can also be taken. conclusion the present era of medical education emphasizes on students' expectations of a clinical teacher to be approachable professional, a positive role model along with having good interpersonal and teaching skills. conflict of interest: none grant support & financial disclosures: none acknowledgements special thanks to final year students who facilitated in data collection. references 1.šimunović vj, hozo i, rakić m, jukić m, tomić s, kokić s, et al. new paradigm in training of undergraduate clinical skills: the neptune-cs project university school of medicine. croat med j. 2010 ; 51(5):373-80. 2.benner p, hughes rg, sutphen m. clinical reasoning, decision making, and action:thinking critically and clinically. in: chapter 6: patient safety and quality: an evidence-based handbook for nurses. rockville (md): agency for healthcare research and quality (us); 2008 apr. chapter 6. 3.peters m, ten cate o. bedside teaching in medical education: a literature review. perspect med education [internet]. 2014; 3(2):76–88. availablefrom: http://www.ncbi.nlm.nih.gov/pubmed/24049043. 4.ramani s, leinster s. amee guide no. 34: teaching in the clinical environment. med teach [internet]. 2008; 30: 347–64. 5.bates t, poole g. effective teaching with technology in higher education: foundations for success. jossey-bass high adult educ ser [internet]. 2003;336. available rom: http://books.google.com/books?id=wq6daaaamaaj &pgis=1. 6.cruess sr, cruess rl, steinert y. role modelling-making the most of a powerful teaching strategy. bmj noor-i-kiran et al. 17jafmdc jan-june 2019;vol.1, no.1 author`s contribution noor-i-kiran naeem: conceived, designed and data collection, analysis and manuscript writing. haris iqbal : data analysis, interpret results, review and final approval of manuscript. wajid butt: study designed , data collection ,writing manuscript , editing of manuscript. page 12 page 13 page 14 page 15 july december 2019; vol. 1, no. 2 j aziz fatm med den clg 63 original article impact of anthropometric parameters on peak expiratory flow rate komal atta, sadaf zia, farkhanda jabeen abstract objective: the aim of the study was to determine the variation of peak expiratory flow rate (pefr) with various anthropometric measurements. methodology: it was a cross sectional study conducted university medical and dental college faisalabad from august 2019 to september 2019.the study comprised of 210 participants of age 18 to 25 years. a detailed history regarding smoking, respiratory disease and allergies were taken. body mass index (bmi) was calculated from recorded height and weight. pefr was measured by peak flow meter. data was analyzed by spss 21. mean and sd was calculated for continuous variables. percentages were estimated for categorical variables. anova and ttest were used for comparison of mean between the groups. association of pefr with anthropometric measurements was analyzed by regression analysis. results: of total population of 210 subjects, 60.5% were males 39.5% were females. mean pefr was higher in tall than short heighted subjects. this difference was significant. (p value=0.005*). significant difference in mean pefr was also noted with respect to weight distribution of subjects (p value = 0.01*). on analyzing the subjects on the basis of bmi, we observed lower pefr values in underweight and obese subjects in contrast to subjects with normal bmi, however this difference was not significant (p value = 0.42). pefr was positively associated with height (p value = 0.004*) pefr was not significantly associated with age, weight and bmi. conclusion: pefr was positively influenced by height and taller subjects have greater pefr values than short heighted subjects. age, weight and bmi have no impact on pefr. keywords: peak expiratory flow rate, anthropometric measurements, obese. introduction peak expiratory flow rate (pefr) is a simple and reliable diagnostic tool used for the assessment of pulmonary function for researches as well as clinical settings.1it is expiratory parameter which estimates the caliber of the large airways.2 it is a simple index of lung functions and commonly used in clinical setups for diagnosis and the assessment of progression of air way obstruction including asthma.3 it is proved to be a valuable tool in lung function studies for selection of the treatment regimens.4 its normal values vary according to racial, geographical, genetic and nutritional background. _____________________________________________________________________ dr. komal atta (mbbs, mphil) assistant professor university medical and dental college, faisalabad dr. sadaf zia (mbbs, mphil) associate professor university medical and dental college, faisalabad dr. farkhanda jabeen (mbbs, mmch) assistant professor m. islam medical and dental college, gujranwala correspondence: dr. komal atta email: komal.atta@gmail.com evidences are available showing impact of age, height, weight and body mass index (bmi) on pefr, however concerning these always conflicting result have been reported. bmi is an indicator of overweight and obesity and has been found to be associated with pulmonary function parameters.5 many previous studies have documented negative impact of obesity on respiratory parameters due to overall distribution of body fat which limits diaphragm expansion that results in impaired pulmonary function and airway hyper-responsiveness.5,6 significant differences have been documented in the pulmonary pressures and pefr among the various diverse ethnicities most probably because of variation in body surface area, height and body mass index. different ways of lifestyle including physical activity has effect on pefr.3 it is imperative to determine the accurate pefr measurement of population of industrialized regions in respect to distinct influencing factors and to suggest normal reference values as they are more prone to airway obstruction and airway hypersensitivity. current study was designed to determine pefr values in non-smoker healthy employees of a private medical college in faisalabad. these people are more prone to airway obstruction due mailto:komal.atta@gmail.com july december 2019; vol. 1, no. 2 j aziz fatm med den clg 64 to excessive smoke and waste disposal in the city. we also aimed to evaluate the variation in pefr with age, height, weight and bmi, as there paucity of data concerning this association for faisalabad population. methodology this cross sectional study was conducted at university medical and dental college faisalabad from august 2019 to september 2019, after taking ethical approval. a total of 210 non-smoker subjects of 18 to 25 years of both genders were recruited from the institute by convenience sampling technique. relevant information about ethnicity, occupation, lifestyle, history regarding smoking, allergies and frequent respiratory tract diseases were recorded on predesigned questionnaire. smokers, subjects with history of respiratory disease, structural deformity of spine and thoracic cage like kyphosis, scoliosis and fused ribs were excluded. informed consent from each participant was taken and confidentiality was assured. height in centimeters (cm) and weight in kilograms (kg) were recorded by standard stadiometer (m306800-ade). bmi was estimated by weight in kg/height in m2. physical examination was done to exclude any structural deformity affecting respiratory system. pefr was recorded by peak flow meter following the standard guidelines. the subjects were instructed to inhale and exhale as hard as possible in a single blow into the apparatus. test for each patient was repeated three times and highest reading was taken in account for analysis. statistical analysis was performed by spss 21. mean±sd was estimated for age, height, weight, bmi and pefr. mean values for pefr among gender were compared by student’s t-test. anova was used for comparison of pefr among the various categories of height, weight and bmi. association of dependent variable (pefr) with independent variables (age, height, weight and bmi) was assessed by linear regression analysis. results of regression analysis were expressed as beta coefficient (β). p value ≤0.05 was taken as statistically significant. results the study comprised of 210 male and female participants. 127(60.5%) of total population comprised of males and 83(39.5%) were females. the mean age of study population was 21.94 ± 4.62 years. mean height, weight and bmi of participants were 159 ± 7.27, 62.7 ± 11.5 and 24.6 ± 3.3 respectively. the mean pefr of the study population was 364 ± 63.01 with range 213 to 534 l/min. males have higher pefr values in contrast to females (371±59.6 vs 357±67.6), however the difference was not statistical different (p value =0.42). significant difference was note in pefr values with respect to weight (p value =0.01*),table 1. table 1: variation in peak expiratory flow rate with weight (n= 210) weight (kg) frequency n (%) pefr (l/min) mean± sd 30 50 43 ( 20.5) 380.41 ± 74.72 51 70 111 ( 52.9 ) 372.75 ± 71.03 70 90 56 (26.7 ) 341.62 ± 68.95 p value 0.01* l/min=liters/minute, *statistically significant value at p < 0.05 mean pefr values of shorter subjects were lower as compared to taller subjects, which was statistical significant difference. (p value= 0.005*), figure 1. figure 1: mean peak expiratory flow rate sorted by with height (n= 210) pefr = peak expiratory flow rate, comparison by t-test p value =0.005*, statistically significant value at p <0.05 on analyzing the subjects on the basis of bmi, we found lower pefr values in obese and underweight subjects as compared to normal weight subjects but this difference was not statistically significant (p value =0.28), table 2. regression analysis is showing significant positive association of pefr with height (p value =0.004*). β coefficient of 1.89 shows that increase in 1 cm of height will increase pefr by 1.89 liters/min. pefr is not significantly associated with age (p value =0.12), weight (p value =0.27) and bmi (p value =0.93). 320 340 360 380 400 420 150-160 161-170 171-180 354±70.9 367±68.5 419±46.9 m e a n p e f r ( l/ m in ) peak epiratory flow rate komal atta et al. july december 2019; vol. 1, no. 2 j aziz fatm med den clg 65 table 2: variation in peak expiratory flow rate (pefr) with bmi (n= 210) body mass index (bmi) frequency n (%) pefr (l/min) mean±sd under weight (bmi<18.5 kg/m2) 11 (4.28) 360 ± 97.52 normal weight (bmi=18.5-22.9 kg/m2) 61 (26.19) 384 ± 61.66 over weight (bmi= 23-24.9 kg/m2 29 (13.80) 346 ± 85.11 obese (bmi ≥ 25 kg/m2) 109 (50.95) 355 ± 66.2 p value 0.42 l/min=liters/minute, statistically significant value at p < 0.05 discussion pefr is a valuable tool for assessing airway caliber and obstruction and has a pivotal role in the identification of obstructive and hyperactive pulmonary diseases.7 evidences are available showing impact of anthropometric parameters on pefr values, due to which the pefr varies among residents of different geographic areas and ethnicity. correct assessment of an observed reading of pefr required knowledge for its range in normal subjects.1,3 the present study was focused to explore range of pefr among the residents of faisalabad and to elucidate the impact of age, height, weight and bmi on it which are the key factors for influencing the pefr. the average pefr of participants of current study was between 534 and 213 l/min. a study conducted at karachi also reported the similar range between 580 250 l/min.3 in accordance with current results jena sk also reported the similar reference values of ranged 500 340 l/min for the indian population.9 the present study observed increase in pefr with increase in height and this positive association was found to be statistically significant (p value =0.004*). this observation was supported by the previous research conducted in karachi which also reported the increase in pefr values with increase in height most probably due to greater thoracic volume, greater strength of expiratory muscle and more muscular effort in tall subjects than short heighted subjects.3 similar results were also reported by previous study conducted by sandhu pk in punjab india.7 moreover, our study also identified decrease in mean pefr with increase in weight which was statistically significant difference (p value =0.01*). the association analyzed by regression analysis between these two parameters was negative, however it was found to be statistically non-significant (p value =0.27). this report was in agreement with previous indian study that did not establish any significant association between pefr and weight. current results are contrasted by the report of kuti bp who found the significant positive association between pefr and weight.8 conflicting results have been documented concerning relation of pefr and bmi by various previous researches. on analyzing the impact of bmi on pefr we found interesting relationship showing decline in pefr with increase as well decrease in bmi as compared to normal weight subjects. however we did not establish any significant association (p value = 0.93) between theses parameters. similar observations were made by sandhu pk and his colleagues.7 contradictory results have been reported by jena sk and his colleagues, they documented significant negative correlation between these two parameters.9 present study also found higher pefr values in males as compared to females might be because of greater height of males than females. higher bmi of females than males might be the contributing factor for lower pefr in females in contrast to males. these findings are also in accordance with documentations of dharamshi ha and his colleagues in pakistan.3 mukherjee s and his co-researchers also reported same observations.1 some researchers had reported decline in pefr with advancing age due to senile degenerative changes in bronchial epithelium and loss of strength of respiratory muscles.10 reduction in pefr also attributed to oxidative stress in older age which causes release of elastases and subsequent diminution of elastic recoil activity of lung.10 as we had selected narrow age group of 15-25 years so, we were unable to find the above relationship in our study. mukherjee s documented the reduction in pefr with advancing age in indian population.1 limitations: this is a single center study, results may not be generalized to whole population. conclusion pefr is affected positively by increase in height. weight and bmi have not significant impact on pefr. recommendation: future studies on a larger scale from a general population of faisalabad are required for reference values and generalization of results to whole population. funding source: none. conflicts of interest: none. anthropometric parameters & pefr july december 2019; vol. 1, no. 2 j aziz fatm med den clg 66 references 1. mukherjee s, banerjee g, mahapatra abs. peak expiratory flow rate changes with relevant variables in a population of eastern india. indian j physiol pharmacol. 2018; 62(3): 372-379. 2. nighute s, buge k, kumar s. effect of cigarette smoking on peak expiratory flow rate: a short review. ijcrpp. 2017 dec 10;1(1):3-5. 3. dharamshi ha, faraz a, ashraf e, alam ss, ali a, shakee o, et al. variation of pefr with height, weight and waisthip ratio in medical students. int arch med 2015; 8 (84):1-6. doi: 10.3823/1683. 4. pothirat c, chaiwong w, phetsuk n, liwsrisakun c, bumroongkit c, deesomchok a, theerakittikul t, limsukon a. peak expiratory flow rate as a surrogate for forced expiratory volume in 1 second in copd severity classification in thailand. int j chron obstruct pulmon dis. 2015; 10:1213-1218. 5. wehrmeister fc menezes amb, muniz lc, -mesa jm, domingues mr, horta b l. waist circumference and pulmonary function: a systematic review and meta-analysis .systematic reviews. 2012; 1:55. 6. salome cm, king gg, berend n: physiology of obesity and effects on lung function. j appl physiol 2010, 108:206–211. 7. sandhu pk, bajaj d, mehta k. correlation of peak expiratory flow rate with age and anthropometric parameters in elderly (465 years). natl j physiol pharm pharmacol 2016;6:89-92. 8. kuti bp, kuti dk, omole ko, oso bi, mohammed lo, ologun bg, et al. effects of socio-demographic and nutritional status on peak expiratory flow rates of rural school children in ilesa, nigeria. annals of health research. 2017; 3(2):82-91. 9. jena sk, mirdha m, meher p, misra ak. relation of peak expiratory flow rate to body mass index in young adults. muller j med sci res.2017;8 (1):19-23. 10. medabala t, rao bn, mohesh gm, kumar mp. the effect of ageing on vital capacity and peak expiratory flow rate in healthy non-smoking agricultural workers. int j med health sci. 2012;1(4):47-52. author’s contribution: dr. komal atta study design, data collection, manuscript writing and approval. accountable for provided information. dr. sadaf zia study concept, data collection and drafting, editing and review of article. dr. farkhanda jabeen statistical analysis, interpretation of results, formulation of tables and figures. komal atta et al. http://www.mjmsr.net/searchresult.asp?search=&author=sunil+kumar+jena&journal=y&but_search=search&entries=10&pg=1&s=0 http://www.mjmsr.net/searchresult.asp?search=&author=meena+mirdha&journal=y&but_search=search&entries=10&pg=1&s=0 http://www.mjmsr.net/searchresult.asp?search=&author=purnima+meher&journal=y&but_search=search&entries=10&pg=1&s=0 http://www.mjmsr.net/searchresult.asp?search=&author=akshaya+kumar+misra&journal=y&but_search=search&entries=10&pg=1&s=0 j aziz fatm med den college jan-june 2020; vol.2, no 1 8 original article screening of barbers for hepatitis b and c in faisalabad khurram sohail raja, shakeela naz, faria aslam, noor arshad, amer hayat abstract objective: to screen the barbers for hepatitis b and hepatitis c in faisalabad. methodology: this cross-sectional study was performed by the forensic medicine department of private medical college of faisalabad after approval from institutional ethical committee. the camp for screening barbers was arranged in september 2019 at sargodha road, faisalabad. barbers from different hair saloons of the city were invited 2-3 days before arranging the camp. fifty-five barbers joined the camp for screening. all relevant information was noted on predesigned pro forma. informed consent was taken and blood samples were drawn from each participant for qualitative detection of hepatitis b surface antigen (hbs ag) and antibodies to hcv (antihcv) using one step rapid test devices (accurate) that are based on a lateral flow chromatographic immunoassay technique. statistical analysis was done on spss 21. percentages and frequencies for reactive and nonreactive tests hbs ag and anti-hcv were determined. results: during this study 55 barbers were screened for hepatitis c and hepatitis b. the age range of the screened barbers was 18-35 years. we found that 3 (5.4%) of the barbers were seropositive for hepatitis c and 1 (1.8%) barber was coinfected with hepatitis c and hepatitis b, in contrast to this none of the barbers was found to have hepatitis b only. conclusion: hcv infection is an occupational hazard for barbers, while hbv infection is not found in barbers despite low infectious dose. keywords: barber, hepatitis b, hepatitis c, infection, hepatitis b surface antigen, anti-hcv. introduction chronic blood-borne infectious diseases like hepatitis c (hcv) and hepatitis b (hbv) are health burden globally affecting two billion and 3.9 million people respectively, including an estimated 400 million chronically infected with hbv. 1 hepatitis b and c are global health issue. 1 these diseases can lead to chronic infections and possess high risk for chronic active hepatitis, cirrhosis and hepatocellular carcinoma. 2 acute hepatitis c is clinically silent in majority of infected individuals (75-80%) with tendency of ____________________________________________________________ dr. khurram sohail raja, mbbs, dmj associate professor forensic medicine dr. shakeela naz, mbbs senior demonstrator forensic medicine faria aslam, ms/m.phil clinical psychologist hiv treatment centre fsd dr. noor arshad, mbbs medical officer, children hospital fsd dr amer hayat, mbbs general practitioner 1-2 aziz fatimah medical and dental college fsd correspondence: dr. khurram sohail raja email: iamkhurram@gmail.com spreading infections. 3 most of the subjects remained undiagnosed due to asymptomatic nature of this condition. 2 in numerous regions of pakistan, the traditional practice of shaving at barber shops or from a roadside barber might be a route of blood-borne viral diseases transmission in them as well as in their customers. these professional while performing their duty are more likely prone to exposure of the blood and bodily fluids of their customers due to accidental micro trauma, thence keeping barbers at high-risk populations for hepatitis b and c. 4 furthermore, due to unawareness, potential reuse of contaminated and unsterilized sharp instruments are also accounts for transmission of infection. 5 thus, aforementioned factors increases the risk for contracting of hepatitis in the society. 5 hbv is believed to be 10 time more infectious and easy transmittable through small sharp instruments due to low infectious dose as compared to hcv. 6 the prevalence of hepatitis c in pakistan is the second highest in the world with an estimated 10 million pakistani population (5% of the population) is affected by hcv. recent epidemiological study conducted in punjab pakistan has reported higher prevalence of hepatitis c in faisalabad and okara districts as compared to other regions of punjab. 2 khurram sohail raja et al. j aziz fatm med den college jan-june 2020; vol.2, no 1 9 lack of awareness of barbers concerning their occupational hazard with blood borne infections including hepatitis reported in many knowledge, attitude and practice (kap) studies conducted in pakistan. many high-risk groups like bakers, blood donors, health care workers etc. have been studied in pakistan but literature on sero-prevalence of hepatitis among barbers is scarce. 7 hence the widespread screening for hepatitis in this group is required for the early detection, management and prevention of spreading hepatitis in our society. hence, this study aimed to screen the barbers for hbv and hcv in highly prevalent city faisalabad and opened the horizon for future research on a broader scale. methodology this cross-sectional study was project of emed in collaboration with forensic medicine department of private medical college of faisalabad to estimate the frequency hepatitis c and hepatitis b viral infections among barbers of faisalabad district. the study was approved by the institutional ethical committee (iec/737-19). the camp for screening of barbers was arranged september 2019 at a shopping mall situated at sargodha road faisalabad. two to three days prior to camp; barbers from the hair saloon of abovementioned vicinity were invited for screening. fiftyfive barbers joined the camp for screening. in the first step all coming barbers interviewed and history concerning hepatitis b vaccination recorded on predesigned proforma. informed consent was taken. subjects with other professionals were excluded from the study. in second step the awareness lecture concerning mode of transmission and complications of hepatitis was delivered and then blood samples were taken from each participant for qualitative detection of hepatitis b surface antigen (hbsag) and antibodies to hcv (anti-hcv) using one step rapid test devices (accurate) with sensitivity and specificity 99.4% and 99.5% respectively. rapid test device is based on a lateral flow chromatographic immunoassay technique. statistical analysis was done on spss 21. percentages and frequencies for reactive and non reactive tests for hbsag and anti-hcv were determined. results during this study 55 barbers were screened for hepatitis c and hepatitis b. barbers were not vaccinated against hbv. the age range of the screened barbers was 18-35 years. we found that 3 (5.4%) of the barbers were seropositive for hepatitis c and 1 (1.8 %) barbers was coinfected with hepatitis c and hepatitis b virus. none of the studied barbers was seropositive for hepatitis b only. table 1. reactive and non-reactive tests for hepatitis among barbers (n=55) reactive tests for hepatitis frequency (%) anti-hcv 3 (5.4%) hbsag 0 (0%) co infection with hcv & hbv 1(1.8%) nonreactive tests for hepatitis 51 (92.7) total 55 reactive tests hbsag indicates hepatitis b infection discussion incidence of hepatitis is increasing in pakistan at alarming rates. reuse of sharp instruments like blades, scissors, nail files and contaminated towels by barbers make themselves and their clients more vulnerable for these life-threatening diseases. 8 high incidence accounts for lack of awareness concerning spread and subsequent complications of hepatitis among the barbers. in pakistan, most of the barbers are illiterate and oblivious of transmission of infectious agents through their mal -practicing like circumcision, incision, and drainage of abscesses by using unsterilized contaminated instruments particularly in rural areas. 9 evidences are available documenting higher prevalence of hepatitis in faisalabad as compared to other regions of punjab. numerous studies have been conducted in various regions of pakistan for screening of hepatitis among various occupations, however few studies have conducted for screening of barbers, which is the most risky group due to occupational exposure of sharp instruments. 10 most of the barbers belong to the lower socioeconomic status and only source of income for their families. lethal viral infectious disease in barbers, compromise not only their lives but also affect their families. moreover, there is also chance of transmitting infections in their customers. they are unable to bear the expenditures of hospitals and are usually non-compliant to medications so they lose courage to live and become a burden for their families. we found that that 5.4% of the barbers were seropositive for the hepatitis c. current results are in line with the previous study conducted in lahore that documented 6.97 % of prevalence of hcv in barbers and beauticians. 9 iranian study by khairkhah et al documented 2% of prevalence of hepatitis c in hepatitis in barbers j aziz fatm med den college jan-june 2020; vol.2, no 1 10 iranian population. 11 however the study from obuasi municipality of ghana had reported 0.5% of prevalence of hcv among barbers. 5 the results of iranian and ghana studies are showing lower prevalence of hepatitis c in contrast to our results . 11 we did not find hepatitis b among the barbers, however only one (1.8%) barber was positive for both hbv and hcv. current results are justified by epidemiologic study conducted at sukkur district sindh by abbasi et al, that reported lower prevalence (2.1%) of hbv in barbers and considered it non occupational risk for barbers. 6 however contrary to our results, the study at ghana had reported high prevalence of hbv among barbers and they found 14.5% of their studied barbers were affected by hbv due to lack of awareness concerning transmission of hepatitis. 5 iranian study conducted at tehran reported 9.2% of prevalence of hbv among iranian barbers. current results concerning the co-infections of hbv and hcv in barbers are in line with aforementioned iranian study that also found only one barber having double infection in their study. 11 hepatitis viral infections vary markedly among the barbers of the various regions of word. variations depend upon knowledge concerning mode of transmission of infections and mainly attributed to their safe and unsafe practices of shaving or haircut etc. on their respective shops. public health programs should be arranged concerning assessment of hepatitis infections among the barbers of the community. so, the precaution measures should be taken to prevent this lethal disease in our society. there should be policy for registering barbers by government to check account ability of safe practicing like use of sterilized instruments , use of new disposable blades for each customer, use of antiseptic , cleanliness and selfhygiene, avoidance of surgical procedures like wound drainage and circumcision at barbers shop in order to prevent the transmission of hepatitis by malpractice and ignorance. conclusion hcv infection was found in barbers and it is an occupational hazard for barbers, while hbv infection is not found in barbers. funding source: none. conflicts of interest: none. references 1. nkrumah b, owusu m, frempong ho, averu p. hepatitis b and c viral infections among blood donors from rural ghana. ghana med j. 2011;45(3):97–100. 2. ahsan a, khan az, javed h, mirza s, chaudhary su, shahzad-ul-hussan estimation of hepatitis c prevalence in the punjab province of pakistan: a retrospective study on general population. plos one. 2019;14(4):e0214435. doi: 10.1371/journal.pone.0214435. 3. tahir z, chaudhry ar, muzaffar r, mushtaq s, razzaque a. prevalence of hbv & hcv infection in faisalabad. biomedica2010;26:7679.http://www.thebiomedicapk.com /articles/188.pdf (accessed on 15 april2020). 4. jokhio a, bhatti t, memon s. knowledge, attitudes and practices of barbers about hepatitis b and c transmission in hyderabad, pakistan. east mediterr health j. 2010;16 (10): 1079–1084. 5. adoba p, boadu sk, agbodzakey h, somuah d, ephraim rk, odame ea.high prevalence of hepatitis b and poor knowledge on hepatitis b and c viral infections among barbers: a cross-sectional study of the obuasi municipality, ghana. bmc public health. 2015; 15:1041. doi:10.1186/s1 2889-015-2389-7. 6. abbasi in, fatmi z, kadir mm, sathiakumar n. prevalence of hepatitis b virus infection among barbers and their knowledge, attitude and practices in the district of sukkur, sindh. int j occup med environ health. 2014;27(5):757–765. 7. shah hb, dar mk, jamil aa, atif i, ali rj, sindhu as et al. knowledge, attitudes and practices of hepatitis b and c among barbers of urban and rural areas of rawalpindi and islamabad. j ayub med coll abbottabad. 2015; 27(4):832836. 8. arshad a, ashfaqua. epidemiology of hepatitis c infection in pakistan: current estimate and major risk factors.crit rev eukaryot gene expr. 2017;27(1):6377.doi: 10.1615/critreveukaryotgeneexpr.2017018953. review. 9. akhtaram,majeed s. hepatitis-c virus infection among barbers and beauticians in lahore, an analytical cross sectional study. sci.int.(lahore).2015;27(5):4303-4308. 10. maan ma, hussain f, jamil m. epidemiology of hepatitis c viral infection in faisalabad, pakistan: a retrospective study (2010-2012). afr health sci. 2014;14(4):810815.doi: 10.4314/ahs.v14i4.6. 11. khairkhah t, shamsa a, roohi a, khoshnoodi j, rajabpour vf, tabrizi m et al. analysis of knowledge, attitudes, and prevalence of hepatitis b and c seromarkers among barbers in tehran. hepat mon.2016;16(9):e39416. doi:10.5812/hepatmon.39416. http://www.thebiomedicapk.com/articles/188.pdf(date https://doi.org/10.5812/hepatmon.39416 khurram sohail raja et al . j aziz fatm med den college jan-june 2020; vol.2, no 1 11 author’s contribution: dr. khurram sohail raja study design, data acquisition, revising all intellectual contents of manuscript and approve final version of an article. dr. shakeela naaz manuscript writing, statistical analysis of data, interpretation and write up of results revise and approve the article. faria aslam data collection, manuscript writing and revising final version of article. dr. noor arshad dr. amer hayat data acquisition, manuscript writing and revising final version of article. data collection and revised the final version of manuscript. all authors are accountable for contents of manuscript equally. received: 15 oct 2019, revised received 30 nov, accepted: 15 dec2019 journal.cdr original article obesity as an emerging risk factor for anemia benash altaf, rana khurram aftab, zeeshan ali khan, rana muhammad tahir salam, fakiha behram abstract background:obesity and anemia are important health challenges worldwide particularly in females and children. these conditions are prevalent in most developing countries and have devastating effect on mental as well as physical health. evidences are available showing the association between these two conditions. the aim of the study was to determine the frequency of anemia among obese subjects and to find association between bmi and hemoglobin. methodology:a cross-sectional comparative study comprised of 216 subjects was conducted at aziz fatimah medical and dental college, faisalabad from april 2018 to september 2018. after approval from ethical committee, all the relevant data including gender, age, height and weight were recorded on a predesigned proforma. bmi was 2 calculated with help of a formula height in meter /weight in kg. hemoglobin (hb) levels were obtained by sahli's method. data was analyzed by using spss 21.0. hemoglobin levels were compared between obese and non-obese 2 subjects by mann whitney test. percentages were compared by x . regression analysis was used to find association between bmi and hb. results:study comprised of 216 subjects of mean age 19.9±0.88. of total studied population 38 .0% were obese 2 having bmi ≥ 25kg/m . significant differences were observed in the mean bmi (p value= 0.001*) and hb (p value= 0.021*) between the studied groups. hemoglobin levels were lower in obese individuals than non-obese. (10.4 vs 12.18) regression analysis reveals significant negative association of bmi with hb (β, 1.036, p value =0.000*). conclusion:anemia is more prevalent among obese individuals than non-obese subjects. key words: anemia, bmi, hemoglobin, sahli's method. introduction 3 communicable diseases like, obesity and anemia etc. it is well documented that anemia has a huge impact on cognition level, decreases physical and mental output and labor productivity, hence retards economic and 4 social development. role of negative iron balance in contribution of anemia has been well documented. it is evident that iron homeostasis is affected by obesity and obesity-related insulin resistance. iron deficiency and anemia are frequent findings in subjects with 5 progressing morbid obesity. decreased dietary iron uptake due to lower enterocyte iron absorption can be considered as the pathophysiological hallmark of iron 6 dysregulation in obesity. reduced iron absorption is most probably due to elevated iron regulatory hormone, hepcidin which blocks cellular iron export by blocking iron exporter ferroportin (fpn) found in duodenal 5,7 enterocytes elevation of pro-inflammatory cytokines . which interfere with erythropoietin synthesis and also suppress the response of erythroid precursors to erythropoietin is a well-recognized mechanism in the development of anemia in chronic conditions like 8 morbid obesity. usually iron deficiency develops gradually and become clinically apparent during adolescence when iron requirements are increased, and jafmdc jan-june 2019;vol.1, no.1 dr. benash altaf assistant professor aziz fatimah medical and dental college, faisalabad. dr. rana khurram aftab assistant professor king edward medical university, lahore dr. zeeshan ali khan senior registrar orthopedic dhq hospital faisalabad dr. rana muhammad tahir salam sonologist aziz fatimah hospital, faisalabad. fakiha behram final year student bs bio.tech foreman christian college lahore correspondence: dr. benash altaf email: altafbenash@gmail.com anemia is an intractable public health problem in which oxygen carrying capacity of blood is reduced usually due to reduction in hemoglobin (hb) which is 1 insufficient to fulfill the body requirements. global prevalence of anemia is 43% in developing countries 2 and 9% in developed nations. prevalence of this condition is continuously increasing affecting all the age groups, caused by lack of balance diet in both rural 2 as well as urban areas of developing countries. poor eating habits due to lack of unavailability of balanced diet and lack of knowledge of healthy eating habits are responsible for developing non-communicable and 24 obesity and anemia of means was used. association between haemoglobin (dependent variable) and bmi (independent variable) was analyzed by regression analysis and presented as beta coefficient (β) and standard error (se). result study was comprised of 216 subjects of mean age 19.9±0.88. descriptives of studied population are described in table 1. of total studied population 34.2% 2 were obese having bmi ≥ 25kg/m and 65.7% were non2 obese with bmi ≤ 25kg/m (figure1) significant difference was observed in bmi among the obese and non-obese groups (58.4 vs 21.9) (p value= 0.001*) (table 2). hemoglobin levels were lower in obese individuals than non-obese (10.4 vs 12.28), which was proved to be significant difference at p value 0.021*. of the total obese 53.2% were anemic as compared to 46.8% of non-obese students but difference was statistically not significant at p value 0.77 (figure 2). regression analysis reveals significant negative association of bmi with hb (β= 1.036, p value= 0.000*) indicating obese subject are more prone to develop anemia. in morbid obesity during adulthood. anemia has detrimental effects on the course of obesity-related conditions; thorough screening and management are required for both conditions. objective the objective of the study was to determine the frequency of anemia among obese subjects and to evaluate association of hemoglobin with body mass index (bmi). methodology a cross sectional study was conducted at a faisalabad based medical institute from april 2018 till september 2018. it was comprised of 216 medical students, who were enrolled in this study by convenient non-probability sampling technique after obtaining approval from the ethical review committee. informed consent was taken from each participant before recruiting into the study. relevant information regarding socioeconomic status, dietary habits, medical history about drugs and diseases like, hemoglobinopathies, worm infestation, cardiac diseases, peptic ulcers and menstrual history from the female participants were recorded on predesigned proforma to rule out the other causes for anemia. their physical examination was performed to look for signs of anemia and dehydration. weight and height were measured by a stadiometer by asking the subject to remove his/her shoes. bmi was calculated by the formula 2 weight in kg/height in meter .participants were grouped as obese and non-obese on the basis of bmi cut off values recommended by world health organization (who) for 2 asians. subjects with bmi ≥ 25kg/m were considered as 2 9 obese and ≤ 25kg/m were taken as non-obese. hemoglobin levels were determined by sahli's hemoglobinometer in physiology laboratory. all the steps were carried out cautiously to minimize inaccuracy. to make our results more authenticated hb results obtained from sahli's apparatus were also correlated clinically by general physical examination. hb less than 13gm/dl for male and less than 12gm/dl for females were 4 consider as anemic as per who recommendation. statistical analysis data was analyzed by statistical package for social science (spss) version 21.0. continuous variables like age, height, weight and hb are presented as mean± standard deviation(sd). categorical variable (gender, anemia,obesity) are presented as frequency and percentages. proportions were compared by chi square 2 (x ) test. shapiro-wilk test was used to test normality of the data. p value ≤ 0.05 in shapriowilk test was obtained showing data was not normally distributed. non parametric test (mann whitney test) for the comparison dr. benash altaf et al. 25jafmdc jan-june 2019;vol.1, no.1 variable mean± sd age (years) 19.9±0.88 height (cm) 112.8±52.3 weight (kg) 60.2±14.09 bmi (weight in kg/height in meter 2 ) 34.4±16.2 hb (g/dl) 11.2±1.59 table:1 descriptive statistics of the studied population (n=216) bmi = body mass index, sd= standard deviation hb= hemoglobin variable obese (n= 74) non-obese (n=142) p value mean sd mean sd bmi 58.4 2.71 21.19 2.32 0.001* hb 10.4 1.44 12.28 1.65 0.021* table 2: comparison of study variables among the studied group (n=216) table 3: regression analysis between hemoglobin and bmi (n=216) variable β s.e p value c.i bmi 1.036 0.024 0.000* 0.837 1.23 dependent variable: hb, independent variable: bmi body, p-value≤ 0.05 is considered statistically significant c.i= β= beta coefficient ,s.e= standard errorconfidence interval, bmi = body mass index, sd= standard deviation hb= hemoglobin p-value ≤ 0.05 is considered statistically significant obesity and anemia showed increase levels of hemoglobin in obese subjects 11 showing that they are not prone to have anemia. saxena y et al study showed inverse association of hemoglobin with bmi showing the obese subjects are more prone to 12 get anemia. in current study, out of 216 subjects, 34.2% (n=74) subjects were obese and 65.70% (n=142) were non obese .our study results are also showing that 53.2% of the total obese subjects were anemic in contrast to 46.8% of anemic non-obese students. however, this difference was statistically not significant (p value= 0.77). current study also revealed negative association of bmi with hb (β 0.036, p value 0.000*) indicating obese persons are more prone to have anemia. these results are in accordance with previous studies which reported 10,12 anemia was more prevalent among obese subjects. some studies are not in agreement with current results showing more prevalence of anemia among the 13,14 underweight subjects. researches on broader scale should be conducted to explore the exact mechanism of anemia in obesity. awareness programs should be arranged in order to make population aware concerning hazards of obesity related to anemia. so the young population can adopt healthy habit before they develop obesity and prevent its hazards. conclusion obese subjects have lower levels of hemoglobin than non-obese and they are more prone to develop anemia. limitation of the study in this study we estimated only hb with clinical correlation. other parameters of iron status and inflammation were not included. future studies on a broader scale should be conducted to evaluate the association of bmi with anemia with measuring iron status. conflict of interest:� � none funding: � � � none references 1.le ch. the prevalence of anemia and moderatesevere anemia in the us population (nhanes 20032012). plos one. 2016;11(11): e0166635. doi: 10.1371/journal.pone.0166635. 2.al-alimi aa, bashanfer s, morish ma. prevalence of iron deficiency anemia among university students in hodeida province, yemen. anemia. 2018:4157876. doi: 10.1155/2018/4157876. ecollection .2018 3.qin y, melse-boonstra a, pan x, yuan b, dai y, zhao j, zimmermann mb, etal. anemia in relation to body mass index and waist circumference among chinese women. nutr j. 2013 ;12:10. doi: 10.1186/1475-289112-10. 4.jawed s, tariq s, tariq s, kamal a.frequency of nutritional anemia among female medical students discussion anemia is a global health challenge which is affecting physical as well as mental status of both urban and rural population. main causes of obesity are sedentary life style and consumption of junk food along with the use of smart technologies like laptops, hence cutting down the 10 healthy eating habits and outdoor activities. other contributing factors include hemoglobinopathies, worm infestation and menstrual disorders in female but leading cause is the lack of iron intake due to nutritional deficiency. it has a major health impact on our infants, children and the younger population as well as pregnant ladies. association of anemia with obesity is evident 10 from previous studies. reduced enteral iron absorption most probably due to elevated hepicidin is common contributing factor. previous studies documented the key role of raised hepcidin in developing iron deficiency anemia. it is highly expressed in liver and adipose tissue that interferes with intestinal iron absorption by blocking 12 iron transporters leading to anemia. obese subjects have higher level of hepcidin and low level of serum iron than 5,13 non-obese. other possible mechanism of anemia in obese subjects is elevation of pro-inflammatory cytokines which interfere with erythropoietin synthesis 8 and results in decrease erythropoiesis. previous studies showed inconsistent results for bmi and anemia. some previous studies found anemia in normal weight subjects following underweight, and then obese, and other studies dr. benash altaf et al. 26jafmdc jan-june 2019;vol.1, no.1 chi-square test :p value = 0.77 p-value ≤ 0.05 is considered statistically significant figure 2: percentages of anemia among study groups (n=216) figure 1. distribution of obesity in studied population (n=216) obesity and anemia 10.sunita kb, kallur r. association of anemia with bmi in medical students, a cross-sectional study, indian journal of basic and applied medical research; indian journal of basic and applied medical research. 2016; 6(1): 371-377 11.hemamalini j. anemia in relation to body mass index and waist circumference among andhra pradesh women. j obes weight loss ther.2013;3:3. doi: 10.4172/2165-7904.1000173. 12.saxena y, shrivastava a, saxena v. effect of gender on correlation of anaemia with body mass index in medical students. indian j physiol pharmacol. 2011; 55(4):364–69. 13.shill kb, karmakar p, kibria g, et al. prevalence of iron-deficiency anemia among university students in noakhali region, bangladesh. j health popul nutr. 2014; 32(1):103–10. 14.hanafi mi, abdallah ar, zaky a, et al. study of hemoglobin level and body mass index among preparatory year female students at taibah university, kingdom of saudi arabia. j taibah univ med sci. 2013; 8(3):160–6. of faisalabad.pak j med sci. 2017; 33(2):398-403. doi: 10.12669/pjms.332.11854. 5.aigner e, feldman a, datzc.obesity as risk factor for iron deficiency.nutrients. 2014; 6(9):3587600.doi:10.3390/nu609358.review. 6.mujica-coopman m.f, brito a, lopez de romana d etal. body mass index, iron absorption and iron status in childbearing age women. j trace elem med biol. 2015; 30:215-9. doi:10.1016/j.jtemb.2014.03.008. 7.vuppalanchi r, troutt js, konrad rj, ghabril m, saxena r, bell ln, kowdley kv, chalasani n. serum hepcidin levels are associated with obesity but not liver disease. obesity (silver spring). 2014; 22(3):836-41. 8.nairz m, haschka d, demetz e, weiss g.iron at the interface of immunity and infection. front pharmacol. 2014;5:152. doi: 10.3389/fphar.2014.00152. ecollection 2014. review. 9.world health organization. international obesity task force. the asia-pacific perspective: redefining obesity and its treatment, 2000. dr. benash altaf et al. 27jafmdc jan-june 2019;vol.1, no.1 author`s contribution dr. benash altaf: contributed to data analysis, interpretation of results, write-up editing and formatting of the manuscript. reviewed and approved the manuscript. dr. rana khurram aftab: study design, data collection, writing manuscript and reviewed and approved it. dr. zeeshan ali khan: data collection, writing the manuscript and review and approved it. dr. rana muhammad tahir salam: data acquisition, formulation of tables, formatting and editing the manuscript review the article and approved it. fakiha behram: data collection, data analysis, reviewed and approved the manuscript. all the authors are guarantors of this work and take responsibility for the integrity of the data and the accuracy of the data analysis. page 22 page 23 page 24 page 25 journal.cdr original article seroprevalence of hepatitis b&c and its association with stroke in local population amsal amjad, benash altaf, farah amir ali, mirza aroosa beg abstract background:pandemics of viral origin are spreading at alarming rate worldwide. acquired immune deficiency syndrome human immunodeficiency virus (aids) caused by (hiv), hepatitis b and hepatitis c (hcv) are lethal threats to the human health. hcv remains a serious issue due to long-term consequences of the infection. hcv infection has a role in the development and progression of carotid atherosclerosis and stroke due to altered lipid metabolism. association of hepatitis with stroke is still hypothesized due to conflicting results documented by various researchers. aim of this study is to explore association of hbv and hcv with stroke as the prevalence of this issue in faisalabad is 21% which is higher than other regions of punjab pakistan. methods: this is a hospital-based retrospective study from july 2018 to september 2018 at a private hospital of faisalabad. it comprised of 226 subjects. a , datafter taking ethical approval from the ethic research committee was retrieved from centrally . data was transported to spss 21 for analysis. frequency and database medical records percentages were obtained for categorical variables. association between hepatitis and stroke was tested by chi square and logistic regression to obtained odd ratio. p value≤0.05 was considered as significant. results: mean age of the studied population was 51.2 ± 27.03. 38.5% and 4% of the studied population had hepatitis c and b respectively. hcv was significantly associated with stroke ( p=.005*) conclusion: hcv is more prevalent viral infection in local population and is the independent risk factor for stroke key words: hbv ,hcv, stroke, association, lipid metabolism. introduction transplantations. it is also prevalent among the health care providers who sustain accidental needle pricks while caring these patients. according to the latest figure, about 170 million people are the victim of this lethal virus and are the leading cause of liver transplantation. 0.85-5.5% of the cases with hcv infection are reported by previous 5 studies. hcv is belongs to a family known as flaviviridae with an approximately 9.6 kb single6 stranded, positive sense rna genome. it can be diagnosed by either checking for viral load through the pcr or by looking for the antibodies been produced against the virus itself. unfortunately, no vaccine is available for this rapidly spreading virus. important issue regarding this virus is that it can easily spread from person to person through infected blood and instruments. perhaps, this is one of the reasons why this bug is based worldwide. it is important to highlight un-documented cases especially in third world countries where still many 7 of the cases are left unnoticed. about 80% of the infected subjects develop chronic infection leading to liver cirrhosis. hepatitis 'c' virus also has extra hepatic manifestations like type ii diabetes, autoimmune thyroiditis, cardiovascular and cerebrovascular diseases most commonly ischemic stroke. steatosis, and oxidative stress due to inflammation provoking the carotid atherosclerosis and plaques in most of the cerebral vessels are the contributing factors for the ischemic stroke. steatosis leading to plaque formation 8,9 jafmdc jan-june 2019;vol.1, no.1 dr. amsal amjad � demonstrator aziz fatimah medical and dental college, faisalabad dr. benash altaf � assistant professor aziz fatimah medical and dental college, faisalabad. dr. farah amir ali � professor aziz fatimah medical and dental college, faisalabad. dr. mirza aroosa beg assistant professor sindh institute of urology and transplantation karachi correspondence: dr. benash altaf � email.altafbenash@gmail.com burden of lethal viral infections are continuously increasing at an alarming rate all over the world. world health organization (who) executive board estimated that 1 million mortalities each year are attributed to viral hepatitis which is 2.7% of the total deaths 1 occurring in the world. 11.5% cases of active hepatitis c (hcv) was reported among the general adult pakistani population which is expected to increase in coming decades mainly due to widespread use of 2,3 unsafe medical procedures. hepatitis is caused by one of the five known viruses (a,b,c,d,e) which primarily infects the liver. hepatitis a and e are common in regions where water and sanitation problems exist like 4 pakistan and bangladesh. however, hbv and hcv infections are most commonly found in subjects r e c e i v i n g b l o o d t r a n s f u s i o n s a n d o r g a n . 9 hepatitis and stroke to be 51.2 ± 27.03. out of 226 subjects 50.4% were males and 49.6% were females, showing that male presentation in medical ward was more than females. figure 1 is showing the frequencies of hbv, hcv and stroke. 38.5% and 4% of the studied population was hepatitis c and b seropositive respectively. results reveal that hepatitis c was more prevalent as compared to hepatitis b. taking into account for stroke, 76.5% of patients were reported. figure 2 is indicating that the 79.3% of hepatitis c 2 patients were also affected by stroke. x test shows significant association of hepatitis c with stroke. odd ratio of 1.29 (p value 0.005*, 95% ci) for anti-hcv seropositive patient is showing that these patients have 1.29 times more risk for developing stroke in contrast to seronegative subjects. figure 3 is showing that the stroke is also found in 66% of the seropositive patients; hbsag however, this association was not statistically significant, most probably due to smaller number of hepatitis b patients in our study (p value 0.480). this study also revealed that the hepatitis c and b as well as stroke are more prevalent among females in contrast to males. difference concerning stroke was statistically significant but was not statistically significant in respect to hepatitis among the gender. (table 1) . is most probably due to the fact that virus itself require fat for its replication and virion production by altered metabolism, leading to decrease reabsorption of fat and 8 subsequent hyperlipdimia. this altered lipid metabolism by hcv virus is the most probable explanation of 10 pathophysiology for stroke in hcv infected patients. strong supportive evidences are available showing the association of hcv with stroke but some studies did not find this association. documentation concerning link of hcv and stroke are still controversial so there is need to 12 explore this relationship. current study is aimed to focus on the association of hcv and hbv with ischemic stroke. in support of this, recent researches are available showing cerebrovascular and cardiovascular diseases are commonest ailments affecting our community and subsequently leading to morbidity and mortality. hence, this emerging issue is contributing a great burden on our society. however, it is preventable and 95% of chronic 13 infection can be cured by using the standard protocol and 14 right treatment guidelines. material & methods this is a hospital-based retrospective study of three months from july 2018 to september 2018 at a private tertiary care hospital in faisalabad. after taking ethical approval from the ethic research committee of the concerned hospital and permission from head of respective ward, data was requested to from retrieve centrally with the cooperation database medical records of it department of the hospital however, . informed consent of the patient was not needed as including 11 patient's data was anonymized and decoded. our inclusion criteria was patients admitted in medical ward in this duration with either stroke or diagnosed hbv and hcv. subjects with other diseases were excluded. total of 226 patients were admitted with hbv, hcv and stroke in this duration, which was the targeted population of present study. data of the subjects of interest concerning age, gender and diagnosis was sorted out on excel and transferred to spss 21. it was analyzed for frequency and 2 distribution of hepatitis and stroke, chi square test (x ) was performed to assess the association of hcv and hbv with stroke with 95% confidence interval. to estimate the relative risk, odd ratios were determined by logistic regression analysis. p value ≤ 0.05 was considered to be significant. results current study comprised of 226 subjects from a private tertiary care hospital of faisalabad. mean age was found amsal amjad et al. 10jafmdc jan-june 2019;vol.1, no.1 figure1:frequencies and percentages of hepatitis and stroke among the hospitalized patients (n=226) table 1: distribution of hepatitis and stroke among gender (n=226) gender hepatitis c (anti hcv) hepatitis b ( hbsag) stroke seropositive frequency n (%) seronegative frequency n (%) seropositive frequency n (%) seronegative frequency n (%) frequency n(%) male (114) 42(36.8) 72(63.2) 3(2.6) 111(97.4) 79(69.3) female (112) 45(40.2) 67(59.8) 6(5.4) 106(94.6) 94(83.9 p values 0.33 0.68 0.012* proportions are compared by chi-square test. p value ≤ 0.05 was considered to be significant. hepatitis and stroke socioeconomic status who even don't bear expenditures of hospital and are also non-compliant to medications. different studies reported hcv affected patients have complications that affect their quality of life. one of the 10,12 complications is known to get ischemic stroke. however, results regarding this statement are still inconsistent, so taking this into account liao cc, and his colleagues studied the population at taiwan and found 7 that hcv patients are at risk for developing stroke. past researches documented varying etiologies of stroke in hcv subject. some researchers reported altered cerebral function in the hcv infection which is responsible for cognitive disturbance as well as psycho-neurological 1 9 issue. present study focused to determine the frequencies of various viral infections and stroke. it revealed that during three months 38.5% and 4% of the targeted population was seropositive for anti hcv and hbsag respectively. it is clear from the results that hcv is more prevalent in faisalabad, punjab than other viral infections. this documentation of our study is in agreement with maan ma who in his two year retrospective study at district headquarter (dhq) hospital, faisalabad, estimated 21. 99% of prevalence in faisalabad, punjab, which is slightly higher than other 17 regions of pakistan. highest proportions of hcv serological markers, was found in injection drug users. preventive strategies on intervention and facilitation of access to healthcare program to safe the local population 1 7 are required. this study also found the higher seropositivity for anti hcv and hbsag in females in contrast to males, this finding is in consistent with ramarokoto ce et al study who reported higher frequency of hcv in females than males (71.42% vs 5 28.57%) in his studied population. result of current study was found that the 79.3% of the hcv patients develop stroke and odd ratio of 1.29 (p value 0.005*) is indicating that these patient poses 1.29 times more risk for stroke than patients with other causes. this finding is suggesting that hcv infection is the independent risk factor for stroke. current findings are strongly supported by community-based prospective cohort study by lee mh and his co researches who also labeled the chronic hcv infection as an independent risk predictor of stroke and cerebrovascular deaths with increasing serum hcv 20 rna level. our aim of the study was also to analyze the data for association of hbv with stroke and found 66% of the subjects were with stroke but this association was not significant probably due to less number of hepatitis b patients (p value 0.48) in our collected data. more prospective cohort studies will be needed to figure 2: frequency and percentages of hcv patients with and without stroke. (n=87) amsal amjad et al. 11jafmdc jan-june 2019;vol.1, no.1 figure 3: frequency and percentages of hbv patients with and without stroke. (n= 09) discussion present retrospective study was conducted to determine the frequency of hcv and hbv in the local population and to high light their association with stroke. hepatitis is spreading at a break neck pace worldwide. it is continuously increasing in pakistan involving all the provinces due to increase usage of unsterile syringes, needles, blades, instruments and unchecked blood 15 transfusions while visiting hospitals and barbers . researches in past also reported high incidence of this 16 issue in punjab. very few epidemiological studies are available documenting slightly higher prevalence of 17 hcv in faisalabad than other regions of punjab. data concerning its incidence and risk factors in faisalabad which is third largest city of pakistan with population of 5.28 million 18 are still obscure. lack of awareness and knowledge are highly contributed to its spread and its complications. proper steps must be taken at government level for the awareness of people to make them enough aware of its complications and to make them know that how they can be safe from contracting this infection by seeking proper precautions. patients affected with hcv are not only compromising the quality of their lives but also losing courage to live, subsequently putting the b u r d e n o f t h e d i s e a s e o n t h e i r f a m i l i e s a n d communities.moreover, affected people are from lower hepatitis and stroke 6. naz a, mukry sn, naseer i, shamsi ts. evaluation of efficacy of serological methods for detection of hcv infection in blood donors. a single centre experience. pak j med sci.2018: 34(5):1204-1208. 7. liao cc, su tc, sung fc, chou wh, chen tl. does hepatitis c virus infection increase risk for stroke? a population-based cohort study. plos one. 2012 ;7(2):e31527. doi: 10.1371/journal.pone.0031527. 8. negro f. facts and fictions of hcv and comorbidities: steatosis, diabetes mellitus, and cardiovascular diseases. journal of hepatol. 2014;61(1):s69-78. 9 . f l a m m s l . c h r o n i c h e p a t i t i s c i n f e c t i o n . jama.2003;289(18):2513-7.review. 10. forton dm, allsop jm, main j, foster gr, thomas hc, taylor-robinson sd. evidence for a cerebral effect of the hepatitis c virus. lancet. 2001; 358(9275):38-9. 11. borovecki a, mlinaric a, horvat m, supak smolcic v. informed consent and ethics committee approval in laboratory medicine. biochem med (zagreb) 2018 ;28(3):030201 review. 12. he huang, kang r, zhao z. hepatitis c virus infection and risk of stroke: a systematic review and meta-analysis. plos one. 2013; 8(11):e81305.review 13. feigin vl. stroke in developing countries: can the epidemic be stopped and outcomes improved?.the lancet neurology. 2007 ;6(2):94-7. 14. standard treatment guidelines, 6th edi, 2010 ministry of health (gndp) ghana, isbn 978-9988-12538-7. 15. mahmood h, raja r. risk factors of hepatitis c in pakistan. gastroenterol hepatol open access 2017; 7(6): 00259. review. 16.al kanaani z, mahmud s, kouyoumjian sp, aburaddad lj. the epidemiology of hepatitis c virus in pakistan: systematic review and meta-analyses.r soc open sci. 2018 apr 11;5(4):180257. confirm this association with underlying biological mechanisms in the future. limitation of the study as this is a retrospective study, so it may also include some subclinical hcv infections associated with stroke, which were left un-diagnosed. duration of three months is not sufficient, large duration studies on a broader scale are required for monitoring these trends, and further observation regarding spread of this lethal disease. conclusion hcv is more prevalent viral infection in local population and is the independent risk factor for stroke. there is urgent need for policies and preventive strategies at government level. proper planning is required to eradicate this infection concerning the safety measures, and proper disposal of waste and infective materials in hospitals, as the, most common routes for its spread are the syringes, surgical procedures and blood transfusion. funding source: nil conflicts of interest: nil references 1.who executive board.viral hepatitis. report by the secretariat, 2009. eb126/15.12.2009. nov [last a c c e s s e d o n 3 m a y 2 0 1 2 ] . av a i l a b l e f r o m : http://www.apps.who.int/gb/ebwha/pdf_files/eb 126/b 126_15-en pdf. 2. umer m, iqbal m. hepatitis c virus prevalence and genotype distribution in pakistan: comprehensive review of recent data. world gastroenterol 2016; 22(4):16841700. 3. arshad a, ashfaq ua. epidemiology of hepatitis c infection in pakistan: current estimate and major risk factors. critical reviews™ in eukaryotic gene e x p r e s s i o n 2 0 1 7 ; 2 7 ( 1 ) : 6 3 7 7 . d o i : 10.1615/critreveukaryotgeneexpr.2017018953. review. 4. antony j, celine t. a hospital-based retrospective study on frequency and distribution of viral hepatitis.jglob infect dis .2014; 6(3):99–104 5. ramarokoto ce, rakotomanana f, ratsitorahina m, etal. seroprevalence of hepatitis c and associated risk factors in urban areas of antananarivo, madagascar. bmc infect dis. 2008 ; 8:25. doi: 10.1186/1471-2334-825. amsal amjad et al. 12jafmdc jan-june 2019;vol.1, no.1 https://www.ncbi.nlm.nih.gov/pubmed/29765698 hepatitis and stroke 19. sheikh my, choi j, qadri i, friedman je, sanyal aj. hepatitis c virus infection: molecular pathways to metabolic syndrome. hepatology. 2008 ; 47(6):2127-33. 20. lee mh, yang hi, wang ch, jen cl, yeh sh, liu cj, you sl, chen wj, chen cj. hepatitis c virus infection and increased risk of cerebrovascular disease. stroke. 2010 ;41(12):2894-900. 17. maan ma, fatma h, muhammad j. epidemiology of hepatitis c viral infection in faisalabad, pakistan: a retrospective study (2010-2012). african health sciences. 2014;14(4):810-4. 2018:http://worldpopulationreview.com/territories/punj ab-population. amsal amjad et al. 13jafmdc jan-june 2019;vol.1, no.1 author`s contribution dr. amsal amjad: study design, data collection, interpretation of results, manuscript writing dr. benash altaf: statistical analysis, interpretation of results, formulation of tables, writing the manuscript. reviewed and approved the manuscript. dr. farah amir ali: acquisition of data, interpretation of results, editing and formatting the manuscript. reviewed and approved the manuscript. dr. mirza aroosa beg: statistical analysis, interpretation of results, formulation of tables, writing the manuscript. reviewed and approved the manuscript. 18. world population review: report,punjab population page 7 page 8 page 9 page 10 page 11 j aziz fatm med den college july december 2020; vol. 2, no. 2 35 from editor’s desk acknowledgement launching of new peer reviewed medical journal was challenging tasks, with the publication of 2nd issue of volume 2 of journal of aziz fatimah medical and dental college (jafmdc); our journal has completed 2 years of production. during this tenure we have published 4 peer reviewed medical journals (2 volumes with 2 issues in each) with great success. it is an honor to get numerous letter of appreciation from all over the pakistan. we achieved our first milestone by hardships and joint efforts of editorial team and now we are eligible to apply for its recognition by higher education commission (hec). we initiated this journal with the goal to produce a high-quality, plagiarism free peer reviewed journal in field of medical sciences that adds information to the world’s medical literature from pakistan. this success is impossible without the vision of mr. muhamad idrees (managing trustee) who always encourages us to go beyond our comfort zone to achieve the set milestone. i would like to pay my especial gratitude to mr. ijaz hussain (executive director) to support in all the logistic required for this journal. on achieving the first milestone, as an editor, i wish to extend my thanks to jafmdc’s editorial board members especially to dr. farah amir ali, dr. benash altaf and dr. mirza aroosa beg for helping me to achieve this task. on behalf of my team, i am grateful to our worthy principal noorakbar sial and senior manager administrator mr. aftab ali khan, who have always been the pillar of unconditional support in all matters. as jafmdc achieved its first milestone, we would like to acknowledge all authors who submitted their valuable research work to jafmdc in spite of knowing that this is a new medical journal and still in phase of struggling for recognition with hec. of course, the contributions of reviewers towards jafmdc are also appreciating that help us in provision of articles up to the mark of scientific excellence for readers. we are also grateful to the legends of medical journalism mr. shaukat ali jawaid, dr fatema jawad, dr. akhter sherin, dr. jamshed akhter, whose guidance during certificate in medical editing course (cme) at university of health sciences lahore (uhs) helped us to overcome our shortcomings. once again especial regards to mr.shaukat ali jawaid for his valuable suggestions to improve the quality of jafmdc. we are thankful to dr. masood jawaid for his guidance concerning open journal system (ojs) for transparent processing of articles. now we are waiting for the advanced cme course to get more guidance concerning indexing of the journals. we hope that our journal will continue to be an important conduit for scientific information with international standards. editor jafmdc dr. shireen jawed email: drshireenjawed@gmail.com j aziz fatm med den college july december 2020; vol. 2, no. 2 43 original article plasma glycated hemoglobin and sleep patterns in local patients with type 2 diabetes mellitus nabeel nasir, muhammad rustam waseem, mirza zeeshan sikandar, asim mumtaz, syed imran ali shah abstract objective: to ascertain glycemic control and sleep quality in patients with type 2 diabetes mellitus and compare them with age-matched non-diabetic control subjects. methodology: in this cross-sectional study, plasma glycated hemoglobin (hba1c) levels and sleep patterns in diabetic subjects were compared with non-diabetic control subjects. ethical approval was granted by the institutional ethical review board of central park medical college vide number cpmc/irb/1728. after taking written informed consent, a total of fifty participants between the ages of 40-60 years were recruited by convenience sampling from the medical outpatient clinic at central park teaching hospital in 2018. based on the fasting blood glucose levels, participants were categorized as group i (diabetic subjects) and group ii (non-diabetic control subjects). sleep quality was assessed using two validated scales, namely insomnia severity index (isi) and epworth sleepiness scale (ess). hba1c levels were evaluated using standardized blood assays. independent samples t-test was employed to determine mean differences between the two groups. a p-value of ≤ 0.05 was considered significant. results: mean age of the study participants (n=50) was 49.28±2.34 years. the diabetic subjects had significantly higher hba1c levels (10.15±2.50 vs. 6.26±1.04; p-value 0.001) and isi scores (12.64±7.91 vs. 4.68±4.88; p-value 0.000) as compared to non-diabetic control subjects, indicating poorer glycemic control and greater degree of insomnia. conclusion: poorly controlled diabetes mellitus as reflected by higher hba1c levels is associated with increased insomnia. keywords: diabetes mellitus, glycated hemoglobin, insomnia, insulin resistance introduction diabetes mellitus is a group of indisputably pervasive metabolic irregularities distinguished by hyperglycemia which may either result majorly from lack of insulin production by the pancreas called type1 diabetes mellitus (tdm1) or a combination of insulin resistance and relative insulin insufficiency called type ii diabetes mellitus (tdm2). ____________________________________________________________ nabeel nasir mbbs student cmh lahore medical and dental college, lhr muhammad rustam waseem mbbs student central park medical college, lhr mirza zeeshan sikandar mbbs student central park medical college, lhr, dr. asim mumtaz mbbs, m.phil professor pathology, akhtar saeed medical and dental college, lhr, dr. syed imran ali shah mbbs, dic, ph.d professor biochemistry central park medical college, lhr correspondence: professor dr. syed imran ali shah email: s.shah10@alumni.imperial.ac. prevalence of diabetes mellitus in pakistan has rapidly increased in the last decade. up to 35.5 million patients were reported in 2017, making pakistan one of the largest diabetic populations in the world.1 sleep related disorders such as insomnia, narcolepsy and obstructive sleep apnea are more commonly observed in diabetic subjects as compared to nondiabetic subjects.2,4 the co-existence of such disorders with diabetes has unpropitious effects on glycemic control which further exacerbate the condition.5,6 insomnia predisposes not only to diabetes mellitus, but also to hypertension, obesity, stroke and heart attack.7bringing into context the sequelae of insomnia, affected diabetic patients are subjected to higher mortality rates and poorer quality of life. symptoms of diabetes such as polyphagia, polyuria and polydipsia additionally worsen quality of sleep, forming a vicious circle.8,9 thus, evaluation of sleep patterns and its quality in the local diabetic population is crucial in understanding and mitigating of long-term deleterious diabetes. glycated hemoglobin (hba1c) is form of hemoglobin found normally in the blood whose levels are elevated exclusively in diabetic patients.10 body glucose is directly proportional to the amount of hba1c j aziz fatm med den college july december 2020; vol. 2, no. 2 44 present in an individual’s blood. the hba1c test, typically conducted at an average of three months, is a convenient means of diagnosing and evaluating diabetic patients’ health. regular hba1c testing to monitor glycemic control is imperative for establishing the adequacy of disease management regimen.11,12 poor glycemic control in subjects with tdm2 as signified by elevated hba1c levels may potentially lead to sleep disturbances and vice versa. there remains a need to study the adequacy of glycemic control in the local tdm2 population, particularly in light of its impact on the quality and quantity of sleep. the present study addressed this need by determining hba1c levels and sleep parameters in patients having tdm2 from the local population and comparing them with age-matched non-diabetic control subjects. methodology the cross-sectional analytical study was carried out at central park medical college, lahore from 1st january to 31st december 2018. ethical approval was obtained from the institutional ethical review board of central park medical college, lahore vide number cpmc/irb/1728. a total of fifty individuals, both males and females, between the ages of 40 and 60 years were enrolled in the study after taking written informed consent. the subjects were recruited from the medical outpatient clinic of central park teaching hospital, lahore by using convenience sampling technique. fasting blood glucose analysis was done for all participants using glucometer (accu chek active glucometer). study participants were divided into two groups on the bases of fasting blood glucose levels, as cut off points described by american diabetic association’s criteria for diabetes.13 twenty five subjects having fasting blood glucose level of 126 mg/dl or greater on two separate occasions were categorized as group i (diabetic group).another 25 non-diabetic individuals with a fasting blood glucose level of less than 100mg/dl were categorized as group ii (control group).participants with fasting blood glucose between 100mg/dl to 125mg/dl excluded. relevant demographic data (age, sex) were procured on the predesigned proforma. plasma hba1c levels were measured using standardized blood assays. based on the american diabetic association’s guidelines, hba1c of 6.5% or above was considered as poor glycemic control.13 afterwards, participants’ sleep quality was assessed by employing the epworth sleepiness scale (ess) and insomnia severity index (isi). ess is a self-administered tool comprising eight items. it employs a four-point scale to assess an individual’s degree of daytime sleepiness with scores ranging from 0 to 24. higher scores indicate more daytime sleepiness.14 isi is a seven item questionnaire that measures the severity, character and influence of insomnia. it also uses a four-point scale with total scores ranging from 0 to 28.15 more severe insomnia is indicated by a higher score. statistical analysis: data was analyzed using spss version23.the entered data was checked for errors and/or omissions. mean±sd were given for normally distributed quantitative variables. frequencies or percentages were demonstrated for categorical variables. independent sample t-test was applied to observe mean differences. a p-value of ≤0.05 was considered statistically significant. results the mean age of all participants (n=50) was 49.28 ± 2.34 years. group i, with 15 males and 10 females, had a mean age of 49.04±3.06 years and group ii, with 18 males and 7 females, had a mean age of 49.52±2.07years. statistically significant differences were observed between the two groups on isi scores and hba1c levels while ess scores did not show any difference (table 1). the diabetic subjects had significantly higher mean isi scores as compared to non-diabetic control subjects (2.64±7.91 versus 4.68±4.88; p-value 0.000) indicating greater degree of sleeplessness (insomnia) in diabetic patients. table 1: group comparisons of isi, ess and hba1c scores (n=50) parameter group i n=25 group ii n=25 p value mean ± sd mean ± sd insomnia severity index (isi) 12.64 ± 7.91 4.68 ± 4.88 0.000* epworth sleepiness scale (ess) 4.60 ± 3.34 5.56 ± 3.54 0.407 serum hba1c (%) 10.15 ±2.50 6.26 ± 1.04 0.000* *difference is significant at p ≤ 0.05, sd =standard deviation, hba1c= glycated hemoglobin significantly higher mean levels of hba1c were in diabetic patients. significantly higher mean levels of hba1c were observed in diabetic subjects as compared to controls, revealing poorer glycemic control in diabetic patients (10.15±2.50 versus. 6.26±1.04; pvalue 0.001). no significant difference in mean ess scores was observed between the two groups (group i 4.60±3.34 vs group ii 5.56 ± 3.54; p=0.407). nabeel nasir et al j aziz fatm med den college july december 2020; vol. 2, no. 2 45 discussion the present study explored the relationship between glycemic control and sleep in patients with tdm2. comparisons were made with non-diabetic control subjects. significantly higher hba1c levels were observed in diabetics when compared with non-diabetic subjects, that is in accordance with several previous studies which additionally links elevated glycated hemoglobin with higher risk of co-morbidities, more complications and high mortality rate.12significantly higher degree of sleeplessness was observed in diabetic patients which are consistent with findings from a previous study conducted on chinese population showing that higher hba1c level is associated with the sleeplessness and poor sleep quality.6 the present findings are also in line with results from a recent study in which japanese patients with tdm2 with inadequate glycemic control were shown to have poor subjective sleep quality.16 diabetic subjects are more prone to the development of sleep disorders which are particularly associated with poor glycemic control.2,3 inadequate glycemic control has been shown to be associated with sleep apnea.5 elevated blood glucose levels are believed to disrupt normal sleep mechanisms which predispose the affected individuals to the sleep disturbances.6 ineffective management of diabetes mellitus has been linked to poor sleep, possibly due to physical and psychological discomforts associated with the disease.10 day time sleepiness caused by night-time sleeplessness in diabetic individuals has been shown to aggravate depressive symptoms and may further lead to alteration in glucose metabolism.17 surani et al. showed that poor glycemic control leads to imbalance that alter sleep physiology, leading to insomnia in diabetic patients.4 sleep apnea and other sleep disorders are highly associated with obesity, which itself is a common trait of patients who develop tdm2 owing to the insulin resistance seen in obese individuals. regular circadian rhythms are essential for effective insulin production and utilization. sleep disturbances in diabetic subjects have also been shown to cause impairment in glucose metabolism as a result of inappropriate production and/or action of insulin.8 in a recent study on diabetic population with poor sleep quality, high levels of fasting c-peptide and insulin were observed which are all reflective of poor glycemic control. poor sleep quality was also linked with increased risk of diabetic polyneuropathy.18 this study is limited by the relatively small sample size and consequently, by the limited analysis which do not account for possible confounding factors such as gender, weight, relatively wide age range and other comorbid conditions which may influence sleep. the present study only employed questionnaires which shed light on the quantitative aspect of sleep. sleep quality is comprehensive entity which, in addition to subjective questionnaires, requires measurement using objective means such as electroencephalography and autography. furthermore, factors like day-to-day stresses, sleeping habits and working hours have impact on both sleep quantity as well as on quality which is also need to be considered. definitive results could be obtained with carefully designed future studies with higher sample size. conclusion poorly controlled type 2 diabetes mellitus, as reflected by higher hba1c levels, is associated with increased insomnia. adequate glycemic control may improve sleep quality in diabetic patients. funding source: none. conflicts of interest: none. acknowledgement we are thankful to the administration of central park medical college for providing logistic support for the study. references 1. aamir a, ul-haq z, mahar s, qureshi f, ahmad i, jawa a et al. diabetes prevalence survey of pakistan (dps-pak):prevalence of type 2 diabetes mellitus and prediabetes using hba1c: a population-based survey from pakistan. bmj open. 2019;9(2): e025300. doi: 10.1136/bmjopen-2018-025300 2. amra b, bahaee fs, amini m, golshan m, fietze i, penzel t. sleep apnea symptoms in diabetics and their first-degree relatives. int j prev med. 2012;3(2):95-101. pmid: 22347605 3. inkster b, riha r, van look l, williamson r, mclachlan s, frier b et al. association between excessive daytime sleepiness and severe hypoglycemia in people with type 2 diabetes: the edinburgh type 2 diabetes study. diabetes care. 2013;36(12):4157-4159. doi: 10.2337/dc13-0863 4. surani s, brito v, surani a, ghamande s. effect of diabetes mellitus on sleep quality. world j diabetes. 2015;6(6):868-873. doi: 10.4239/wjd.v6.i6.868 5. keskin a, ünalacak m, bilge u, yildiz p, güler s, selçuk e et al. effects of sleep disorders on hemoglobin a1c levels in type 2 diabetic patients. chinese med j. 2015;128(24):3292-3297. doi: 10.4103/0366-6999.171415 6. zhu b, li x, wang d, yu x. sleep quality and its impact on glycaemic control in patients with type 2 diabetes mellitus. int j nurs sci. 2014;1(3):260-265. doi: 10.1016/j.ijnss.2014.05.020 hba1c and sleep pattern j aziz fatm med den college july december 2020; vol. 2, no. 2 46 7. colten hr, altevogt bm, editors. sleep disorders and sleep deprivation: an unmet public health problem. institute of medicine (us) committee on sleep medicine and research; washington (dc): national academies press (us); 2006. doi:10. 17226/11617.https://www.nap.edu/catalog/11617/sleep-disorders -and-sleep-deprivation-an-unmet-public-health-problem.[cited on may 2nd, 2020] 8. lloyd a, sawyer w, hopkinson p. impact of long-term complications on quality of life in patients with type 2 diabetes not using insulin. value in health. 2001;4(5):392-400. doi: 10.1046/j.1524-4733.2001.45029.x 9. ishak ww, bagot k, thomas s, magakian n, bedwani d, larson d et al. quality of life in patients suffering from insomnia. innov clin neurosci. 2012;9(10):13-26. pmid: 23198273 10. takahashi s, uchino h, shimizu t, kanazawa a, tamura y, sakai k, et al. comparison of glycated albumin (ga) and glycated hemoglobin (hba1c) in type 2 diabetic patients: usefulness of ga for evaluation of short-term changes in glycemic control. endocrine j. 2007;54(1):139-144. doi: 10.1507/endocrj.k06-103 11. sherwani si, khan ha, ekhzaimy a, masood a, sakharkar mk. significance of hba1c test in diagnosis and prognosis of diabetic patients. biomark insights. 2016;11:95-104. doi: 10.4137/bmi.s38440 12. morin cm, belleville g, bélanger l, ivers h. the insomnia severity index: psychometric indicators to detect insomnia cases and evaluate treatment response. sleep. 2011 ;34(5):601-8. doi: 10.1093/sleep/34.5.601. 13. sakamoto r, yamakawa t, takahashi k, suzuki j, shinoda mm, sakamaki k, et al. association of usual sleep quality and glycemic control in type 2 diabetes in japanese: a cross sectional study sleep and food registry in kanagawa (soreka). plos one 2018;13(1):e0191771. doi: 10.1371/journal.pone.0191771 14. d’emden mc, shaw je, colman pg, colagiuri s, twigg sm, jones grd, et al. the role of hba1c in the diagnosis of diabetes mellitus in aust. med j australia. 2012;197(4):220-221. doi: 10.5694/mja12.10988 15. american diabetic association. diabetes overview – diagnosis (internet). [cited 26th june 2020]. available from: https:// www. diabetes.org/a1c/diagnosis 16. johns m. the epworth sleepiness scale about the ess (internet). [cited june 25th 2020].availablefrom: http:// epworth sleepinessscale.com/about-the-ess/ 17. medeiros c, bruin v, férrer d, paiva t, júnior rm, forti a, et al. excessive daytime sleepiness in type 2 diabetes. arq bras endocrinol metab. 2013; 57 (6):425-430.doi:10.1590/s000427302013000600003 18. choi d, kim b, jung c, kim c, kang s, mok j. diabetic complications associated with poor sleep quality in type 2 diabetes. diabetes 2018; 67(supplement 1):820. https://doi.org/ 10. 2337/db18-820-p author’s contribution: nabeel nasir study design, data collection, analysis, drafting and finalization of this manuscript. muhammad rustam waseem study design, data collection, analysis, drafting and finalization of this manuscript mirza zeeshan sikandar dr. asim mumtaz dr. syed imran ali shah: study design, data collection, analysis, drafting and finalization of this manuscript conception and design of the study, drafting, review, revision and finalization of this manuscript. responsible for conception and design of the study, as well as drafting, review, revision and finalization of this manuscript. the manuscript has been seen and approved by all authors received: 18 june 2020, revised received: 10 sep 2020, accepted: 15 sep 2020 nabeel nasir et al https://pubmed.ncbi.nlm.nih.gov/21532953/ https://pubmed.ncbi.nlm.nih.gov/21532953/ https://pubmed.ncbi.nlm.nih.gov/21532953/ journal.cdr original article screening of blood donors for transfusion transmitted infections in tertiary care hospital of faisalabad sarwat jahan, saira mushtaq, farah amir ali abstract background:blood transfusion saves millions of lives worldwide each year and reduces morbidity but at the same time is a source for potentially life threatening transfusion transmissible infections (ttis). these ttis are a threat to blood safety. sensitive screening with advanced technologies reduces the risk of ttis, but it still remains a major concern. objective of this study was to determine the frequencies of various abo blood groups and to screen the ttis like hepatitis b (hbv), hepatitis c (hcv), human immunodeficiency virus (hiv), syphilis and malaria among voluntary and replacement blood donors of faisalabad. methodology:this cross sectional study was conducted at aziz fatimah hospital faisalabad, from july 2018 to november 2018. after taking informed consent all replacement and voluntary blood donors were screened for hcv, hbv, hiv, syphilis and malaria. results:during 5 months of study period, total 1942 patients, of age ranged were screened for ttis. all 18-40 years, blood donors were male; no female came to donate blood during this duration. highest percentage of study population were blood group b (36.9%), followed by blood group o (28.1), a (22.2%), and ab (9.2%) respectively. frequencies and percentages of rhesus blood groups exhibited the predominance of positive rhesus groups in the study population. out of total donors, 78 (4%) were infected with hcv, 30 (1.5%) with hbv, 10 (0.5%) with hiv, 19 (1 %) with syphilis and 3(0.20%) were seropositive for malaria. therefore, 140 (7.2 %) blood donors out of total were seropositive for various ttis. conclusion:this study showed the seroprevalence of transfusion transmitted infections (ttis) among the blood donors. highest percentage of blood donors suffered from hcv, followed by hbv, syphilis, hiv and malaria. key words: transfusion transmitted infections, human immunodeficiency virus, hepatitis b virus, hepatitis c virus, syphilis, malaria introduction 2 can result in immediate or late complications. these complications have resulted in substantial disagreeable health outcomes leading to an increased frequency of morbidity and mortality. therefore transfusion-related safety is of utmost importance and cannot be 3 overemphasized. to ensure the safe blood for transfusion, a blend of cautious donor selection and sensitive screening with advanced technologies and viral 2 inactivation procedures were used. these protective measures though have dramatically reduced the risk of transfusion transmissible infections (ttis), but it still 1, 2 remains a major concern. blood transfusion continues to be a major source of viral, bacterial and parasitic 2,4 infections. blood donation during window period might transmit diseases to the recipients and prevalence of these asymptomatic carriers poses a serious challenge 1 to blood safety. hepatitis b and c are most common blood borne infections due to use of unsafe injections and unhygienic instruments blood for donation are . commonly screened for these infections. however latest studies have reported increased prevalence of other transfusion related infections in addition to hbv and hcv, especially acquired immunodeficiency syndrome (aids) caused by human immunodeficiency viruses (hiv), syphilis caused by spirochaete, treponema jafmdc jan-june 2019;vol.1, no.1 sarwat jahan assistant professor aziz fatimah medical and dental college (afmdc), faisalabad, dr saira mushtaq assistant professor aziz fatimah medical and dental college (afm&dc), faisalabad, dr farah amir ali professor aziz fatimah medical and dental college (afmdc), faisalabad, correspondence dr. sarwat jahan, email:drsarwat78@hotmail.com blood donation is an intricate procedure comprising of collection, testing, preparing, and storing of blood and 1 blood components. blood donors can be of two types; 2 voluntary blood donor and replacement blood donors. blood donated by these donors is then utilized in carrying out blood transfusions. in pakistan, approximately, greater than 1.5 million units of blood 2 are collected each year. the majority of these donors are replacement donors, mostly family members or friends of the patients with the intention to help in 3 e m e rg e n c y s i t u a t i o n . b l o o d t r a n s f u s i o n i s a methodology orchestrated routinely in tertiary hospitals as an indispensible technology. however, it 28 transfusion of transmitted infections in blood done by enzyme-linked immunosorbent assay (elisa) method for hiv and hepatitis b and c. hiv testing was done using fourth generation elisa kits. syphilis was tested by latex agglutination assay and malaria was tested u s i n g s l i d e m e t h o d a n d b y r a p i d i m m u n e chromatographic assay. any sample found reactive, was retested for confirmation. seropositive units were discarded to avoid contamination. the criteria for validity of elisa tests given by the manufactures were considered. cut off value for reporting positive results was calculated as per manufacturer's directions. all laboratory records were maintained by central data base of the hospital. for analysis data were retrieved and transported to spss version 22 for analysis. frequencies and percentages for various blood groups, seropositive (reactive) and seronegative (non-reactive) tests for hbsag, hcv, hiv, syphilis and malaria (ttis) were obtained. results during 5 months duration of study, total 1942 patients came to hospital for blood donation and they were screened for ttis. all blood donors were male; no female came to donate blood during this duration. blood donors were of age range distribution of abo 18-40 years. blood groups is indicated in figure.1. among 1942 blood donors, 743(36.9%) belonged to blood group b, 447 (22.2%) belonged to blood group a, 567(28.1%) were of blood group o and 185(9.2%) had blood group ab. highest percentage of study population were of blood group b followed by o, a and ab respectively (figure.1). frequency and percentages of rhesus blood groups were showing the predominance of positive rhesus groups i.e 1757 (90.4%) in study population, while only 185(9.5%) of population was rhesus negative. data regarding seropositive and seronegative for various ttis is presented in table1. out of these donors 78 (4%) were infected with hcv, 30 (1.5%) with hbv, 10 (0.5%) with hiv, 19 (1%) with syphilis and 3(0.20%) were seropositive for malaria (table 1). of total, 140 (7.2%) blood donors were seropositive for various ttis. 4 pallidum and malaria. transfusion-transmitted malaria (ttm) is most frequently caused by plasmodium, falciparum and malariae. in the recipient's bloodstream it triggers the development of high risk complications leading to a lethal outcome especially in individuals with no previous exposure to malaria or in immuno5 compromised patients. transfusion-transmitted syphilis (tts) is also a serious public issue in developing countries. according to world health organization (who), among 12 million new cases of syphilis, more than 90% cases are reported in developing countries, 6 each year. who recommends screening of all donated blood for syphilis and malaria, but it is challenging for many countries with poor resources. blood banks in lowincome countries do not screen donated blood for 7 syphilis, as it is unaffordable for many patients. along with the screening of the hepatitis and hiv there is emergent need to screen for syphilis and malaria. morbidity and mortality from the transfusion of infected blood have inculcated more alarming condition, not only for the recipients but also for their families and communities worldwide. risk for ttis needs to be taken into account in order to enhance the safety of the blood donation by means of appropriate screening of blood. ensuring sufficient supplies of safe blood and prevention of transmission of transfusion-transmissible infections are major public health responsibilities of every government and health professionals. aim this study was designed to screened blood for transfusiontransmitted infections (tti) like hbv, hcv and hiv, syphilis and malaria among voluntary and replacement blood donors of faisalabad and secondarily to determine the frequencies of various abo blood groups among them. methodology this cross sectional study was conducted at aziz fatimah hospital faisalabad from july 2018 to november 2018. ethical approval was taken from ethical committee of the hospital prior to commencement of the study. all replacement and voluntary blood donors, who came to the hospital for blood donation in this duration, were included in study. all professional blood donors and addict persons were excluded. every unit of the collected blood for donation were screened for transfusion transmitted infections including hepatitis b surface antigen (hbs ag), hcv, hiv, syphilis, and malaria. prior to screening, informed consent was taken from each blood donor. screening of blood units was sarwat jahanet al. 29jafmdc jan-june 2019;vol.1, no.1 table 1: frequencies of transfusiontransmitted infections (tti) n = 1942 transfusion-transmitted infections (tti) reactive test non-reactive test n (%) n (%) hepatitis b (hbsag) 30 (1.5) 1912 (98.5) hepatitis c (anti-hcv) 78 ( 4) 1864 (96) hiv 10 (0.5) 1932 (99.5) syphilis 19 (1) 1923 (99) malaria 3 (0.20) 1939 (99.8) transfusion of transmitted infections in blood reported significantly lower frequency of hbv (less than 2% )as compared to our findings and other studies 17 reported from pakistan. in our study, the frequency of hcv in the blood donors was also much higher (4%) as compared to that reported by other researchers. i.7% is reported by arshad a et al from karachi, saghir et al 14,18 (0.79%) and by el-hazmi mm et al (0.4 %). our study showed high rate of hcv through blood transfusion in faisalabad as compared to other regions of pakistan. however our findings were lower than the previous studies conducted in faisalabad which was evident for rising prevalence of hcv in faisalabad than other regions of punjab. ahmed n etal reported prevalence of 16% hcv patients among the blood donors visiting to 1 9 allied hospital faisalabad. another study from faisalabad also reported higher prevalence of 21.99% of 20 hcv in general population. different rates between current and previous studies can be justified by the fact that our study sample comprised of subjects visiting one private hospital of faisalabad, whereas, previous reports included subjects visiting hcv screening camps and blood donors at the huge government sectors. another review documented from faisalabad in 2017 is also evident of rising prevalence of hcv in punjab, which was 5.46%,which is near to our study results and much higher than other regions of pakistan specially sindh. 21 the percentage of hiv-positive blood donors in our study was comparatively higher (0.5%) then the study 15 done in islamabad and bahawalpur (0 %) and 0.04 % of 3 the hiv infections was reported from karachi. however it showed slightly decreasing trend when compared with the results reported in different regions (0.80%) in east 3,15 3,15,22 delhi, india and (0.96%) in nigeria. other studies conducted by attaullah s, manzoor i etal. showed decreasing trend positive cases of 4,23 for hiv in pakistan. syphilis in this study was 0.9% which showed rising trend as compared to 0.34 % in study conducted by saghir et al, 14,15 0.75 % in study conducted by chaudhary et al and 0.1 24 % in port harcourt, south-south, nigeria. another study was conducted in islamabad had also reported a rising seroprevalence of syphilis 0.89% which was very 24 nearer to our study results. similar study conducted in karachi was documented the higher prevalence of 4 syphilis (2%) than all the studies discussed above. previous studies in india also showed very low prevalence as compared to our study. thus, the 2 5 frequency of syphilis observed in our study and other studies conducted in pakistan was higher as compared to 2 5 , 2 6 the other international studies. although, one limitation in our study is that evolution of syphilis could not be assessed clinically and only seropositive results discussion although blood transfusion saves the lives of millions of people worldwide, the patients who undergo blood transfusion are at a potential high risk of transfusiontransmitted infections (ttis). according to our study results, highest percentage of study population were blood group b ( 36.9%), followed by o (28.1%), a (22.2%), and ab (9.2%) respectively. frequency and percentage of rhesus blood groups showed the predominance of positive rhesus groups in the study population. 1757 (90.4%) was rhesus positive, while only 185(9.5%) of population was rhesus negative. similar trends are also reported by the previous studies 8,9 conducted in punjab. the prevalence of hepatitis b virus (hbv) and hepatitis c virus (hcv) in pakistan is 3,10 high (2.5% and 25%) respectively. however latest studies have reported increased prevalence of other transfused related infections especially human 4,11,12 immunodeficiency viruses (hiv) and syphilis. commonly, the diagnosis of hbv, hcv, hiv and syphilis is based on the presence of their respective 13 antigens or antibodies in blood. in this study, we evaluated the seroprevalence of different microbes including hbv,hcv,hiv, syphilis and malaria among 1942 blood donors from the laboratory of faisalabad based hospital. all donors in our study were male of about 18–40 years of age group. a similar trend was seen 14,15 in previous study conducted by saghir et al. in this study, seroprevalence of hcv was highest (4%), hbsag (1.5%) while that of syphilis was (1%) which was seem to be high in comparison to frequency of hiv and malaria (0.5%, 0.2% respectively) among blood donors over the study period of 5 months. previous studies conducted in rawalpindi pakistan and neighbor country iran, showed similar rising frequencies of hbv 2.45% and 2.3% 15,16 respectively. 1.5 % of the population of current study was infected with hbv. similar figures were also reported by arshad a et al, who found seropositivity of 3 hbv in 1.8% in their studied population at karachi. w h i l e s t u d y d o n e i n s r i l a n k a h a s b e e n sarwat jahanet al. 30jafmdc jan-june 2019;vol.1, no.1 figure 1: distribution of blood groups among study population transfusion of transmitted infections in blood transmitted syphilis in teaching hospital, ghana. emerg infect dis. 2011;17(11):2080-2. doi: 10.3201/eid1711.110985 8.kanwal s, qureshi hj, aslam ms, masood s. frequency of abo and rh blood groups in students of akhtar saeed medical and dental college, lahore. pak j physiol 2016;12(1):29–30. 9.khan mu, bashir mw, rehman r, kiani ra. frequency of abo and rh (d) blood groups among blood donors in lahore, pakistan. ij abbr 2014; 29 (3):597-600. 10.memon fa, ujjan id, memon ai, shaikh ar, rao ar,naza.seroprevalence of transfusion transmitted infections among different blood group donorsat blood bank lumhs, hyderabad. pak j med sci. 2017; 33(2):443-446. 11.motayo bo, faneye ao, udo ua, olusola ba, ezeani i, ogiogwa ji. seroprevalence of transfusion transmissible infections (tti), in first time blood donors i n a b e o k u t a , n i g e r i a . a f r h e a l t h s c i . 2015;15(1):19–24.doi: 10.4314/ahs.v15i1.3. 12.ji zh, li cy, lv yg, cao w, chen yz, chen xp, tian m, li jh, an qx, shao zj. the prevalence and trends of transfusion-transmissible infectious pathogens among first-time, voluntary blood donors in xi'an, china between 1999 and 2009. int j infect dis. 2013; 17(4):e259–62. doi: 10.1016/j.ijid.2012.10.006. 13.al-bahrani a, panhotra br. prevalence of hbsag and anti hcv antibodies in blood donors of the al-hasa region of the saudi arabia. ann saudi med. 2001; 21(34):234–235 14.saghir, fm al–hassan et al. frequencies of hbv, hcv, hiv, and syphilis markers among blood donors. trop j pharm res, february2012; 11 (1): 135. 15.chaudhary i a, khan s s, masood r, sardar m a, mallhi a a. seroprevalence of hepatitis b and c among the healthy blood donors at fauji foundation hospital, rawalpindi. pak j med sci. 2007; 23(1): 64-67. 16.alizadeh ah, ranjbar m, ansari s, mirarab a, alavian sm, mohammad k, hekmat l. seroprevalence of hepatitis b in nahavand, islamic republic of iran. east mediterr health j.2006; 12(5):528-537. could hallmark the underlying disease. due to rising trend of syphilis, hcv and hiv among blood donors in pakistan, there is an urgent need for screening of donor's blood for ttis to prevent the blood recipient from transmitted infections as much as possible. such researches will play a key role to improve public health and awareness regarding transfusion transmitted infections and also used to control safety and quality of blood. conclusion this study showed the seroprevalance of transfusion transmitted infections (ttis) among the blood donors. highest percentage of blood donors suffered from hcv, followed by hbv, syphilis, hiv and malaria. blood group b was commonest and ab was least frequent among donors. references 1.blood donor selection. guidelines on assessing donor suitability for blood donation. annex 3. geneva: world healthorganization;2012. http://www .who.int/bloodsafety /voluntary_donation /bl ood_donor _selection_counselling/en/ 2.bhaumik p, debnath k. prevalence of blood-borne viral infections among blood donors of tripura. euroasian j hepatogastroenterol. 2014;4(2):79-82.doi: 10.5005/jp-journals-10018-1106. 3.arshad a, borhany m, anwar n, naseer i, ansari r, etal. prevalence of transfusion transmissible in fections in blood donors of pakistan. bmc hematol. 2016; 16:27. ecollection 2016. 4.attaullah s, khan s, khan j. trend of transfusion transmitted infections frequency in blood donors: provide a road map for its prevention and control.j transl med. 2012;31;10:20. doi: 10.1186/1479-5876-10-20 5.verra f, angheben a, martello e, giorli g, perandin f, bisoffi z. a systematic review of transfusion-transmitted malaria in non-endemic areas. malar j.2018;16; 17(1):36. doi: 10.1186/s12936-018-2181-0. 6.kaur g, kaur p. syphilis testing in blood donors: an update. blood transfus. 2015; 13(2):197-204. doi: 10.2450/2014.0146-14. 7.owusu-ofori ak, parry cm, bates i.transfusion sarwat jahanet al. 31jafmdc jan-june 2019;vol.1, no.1 conflict of interest: �� none funding: ��� none transfusion of transmitted infections in blood blood donors: prevalence and trends in the last three and a half years in a tertiary health mcare facility in ileife,nigeria. inter. j. med. med. sci. 2010; 2: 335-341 23.manzoor i, hashmi no, daud se, ajmal sa, fatima hi, rasheed za, syed sa. seroprevalence of transfusion transmissible infections (ttis) in blood donors. biomedica. 2009; 25(10):154–8. 24.ejele oa, erhabor o, nwauche ca.the risk of transfusion-transmissible viral infections in the nigerdelta area of nigeria. sahel medical journal 2005; 8:1619. 25.bhawani y, rao pr, sudhakar v. seroprevalence of transfusion transmissible infections among blood donors in a tertiary care hospital of andhra pradesh. biol med. 2010;2(4):45–8. 26.waheed u, khan h, satti hs, ansari ma, malik ma, zaheer ha. prevalence of transfusion transmitted infections among blood donors of a teaching hospital in islamabad. ann pak inst med sci. 2012;8(4):236–9. 17.noordeen, f., pitchai, f.n.n. and rafeek, r.a., 2015. a review of hepatitis b virus infection in sri lanka. sri lankan journal of infectious diseases, 5(2), pp.42–50. doi: http://doi.org/10.4038/sljid.v5i2.8087. 18.el-hazmi mm. prevalence of hbv, hcv, hiv-1,2 and htlv-i/ii infections among blood donors. saudi med j 2004; 25(1) 26–33. 19.ahmad n, asgher m, shafique m, qureshi ja. an evidence of high prevalence of hepatitis c virus in faisalabad, pakistan. saudi med j. 2007;28(3):390–395. 20.maan ma, hussain f, jamil m. epidemiology of hepatitis c viral infection in faisalabad, pakistan: a retrospective study (2010-2012).afr health sci. 2014;14(4):810-5. doi: 10.4314/ahs.v14i4.6. 21.arshad a, ashfaq ua. epidemiology of hepatitis c infection in pakistan: current estimate and major risk factors. crit rev eukaryot gene expr.2017; 27(1):6377. 22.salawu l, bolarinwa ra, adegunloye ab, murainaha. hbsag, anti-hcv, anti-hiv, and vdrl in sarwat jahanet al. 32jafmdc jan-june 2019;vol.1, no.1 author`s contribution dr. sarwat jahan: study design, data collection, interpretation of results, manuscript writing dr. saira mushtaq: statistical analysis, interpretation of results, formulation of tables, writing the manuscript. reviewed and approved the manuscript. dr. farah amir ali: acquisition of data, interpretation of results, editing and formatting the manuscript. reviewed and approved the manuscript. page 26 page 27 page 28 page 29 page 30 j aziz fatm med den college january june 2020; vol. 2, no. 1 12 original article evaluation of oxidative stress markers’ status in obese females using hormonal contraceptives fauzia aitazaz, muhammad aurangzeb, radhia khan, samiullah khan, zakia khan abstract objective: to evaluate the variation in oxidative stress markers including superoxide dismutase (sod), catalase and malondialdehyde (mda) and to correlate it with obesity in females using contraceptives. methodology: comparative cross sectional study was a project of university of lahore (uol) in collaboration with basic health unit mudkey (periphery of kasur) from january to december 2013. the study population comprised of 51 married females of age ranged 25 to 40 years. the study was approved by the research ethical committee of uol. thirty-one females either using combined oral contraceptive (coc) pills or progestin injections were enrolled for a period of 9 months, while 20 females not using any type of contraceptives were recruited as a control group. weight in kg and height in meter were estimated by the standard protocol. body mass index (bmi) was calculated by the formula; weight in kg/ height in m2. subjects having bmi greater than 25 kg/m2 were categorized as obese. stress markers were estimated from blood samples. sod was assayed by nitroblue tetrazolium method by spectrophotometer. catalase and glutathione levels were also determined using spectrophotometer. mda levels were measured by thiobarbituric acid assay reaction with mda. statistical analysis was performed by spss 20. for continuous variables mean and sd were determined; while frequency and percentages were used for estimation of categorical variables. beta coefficients for association between obesity and the stress markers were obtained by regression analysis. p-value ≤ 0.05 was taken as statistically significant. results: sod and mda levels were significantly higher in obese group as compared to non-obese group (pvalues 0.02, 0.04). no significant differences were noted in obese and non-obese subjects with respect to catalase (p-value 0.35) and glutathione (p-value 0.9) concentrations. regression analysis shows significant positive association of bmi with sod (p-value 0.006) and mda (p-value 0.000); however, catalase (p-value 0.28) and glutathione (p-value 0.85) were not significantly associated with bmi. conclusion: oxidative stress in obese are due to higher mda levels. sod is positively associated with bmi; however catalase and glutathione are not affected by bmi. keywords: catalase, malondialdehyde oxidative stress, superoxide dismutase introduction obesity is a chronic inflammatory condition-reaching pandemic in developed and developing countries. it is associated with metabolic derangement and oxidative ___________________________________________________________ dr. fauzia aitazaz, mbbs, mphil asst. prof. physiology azad jammu kashmir medical college, muzaffarabad dr. muhammad aurangzeb, mbbs, fcps pathologist cmh, rawlakot radhia khan, msc, phd asst. prof. biochemistry mti bannu medical college, bannu dr. samiullah khan, mbbs, fcps senior registrar of medicine mti khalifa gulnawaz teaching hospital, bannu dr. zakia khan, mbbs, fcps asst. prof. gyneacology mti bannu medical college, bannu correspondence: fauzia aitzaz email: doctorfauzia@gmail.com stress.1 use of contraceptive pills and injections are responsible for obesity in females of reproductive age.2 hyperlipidemia, hyperleptinemia and release of inflammatory cytokines from adipocytes are the contributing factors for over production of reactive oxygen species (ros) including superoxide (o2 -) and hydrogen peroxide (h2o2) that causes oxidative stress, damage to dna and rna leading to cell death.3 moreover, oxidative stress is best reflected by products of lipid peroxidation malondialdehyde (mad).4 in obese subjects accumulation of abdominal fat enhances lipid peroxidation and subsequent production of mda due to excess release of pro-inflammatory cytokine interleukin-6 (il6), tumor necrosis factoralpha (tnf-α) and c reactive proteins (crp).3 these factors are responsible for activating the apoptotic cascade causing cell death and oxidative stress in obese subjects. an antioxidant system is required to prevent oxidetive stress. superoxide dismutase is the key component mailto:doctorfauzia@gmail.com j aziz fatm med den college january june 2020; vol. 2, no. 1 13 of antioxidative system and it proves to be first line of defense against oxidative cell damage induced by reactive oxygen species (ros). it helps in elimination of hydrogen peroxide (h2o2) from superoxide that can be later on decomposed into water and oxygen by the action of another important antioxidant enzyme catalase, thus protecting cell from oxidative damage.5 in previous studies, some have documented higher activity of sod in response to oxidative stress in obese subjects, while others reported contradictory results suggesting lower activity of antioxidant system in obese individuals.6 oxidant-antioxidant status in females using contra-ceptive are still debatable. limited data is available concerning association of oxidative stress and obesity in these high-risk females. keeping in view marked altered oxidative stress and higher prevalence of obesity in females using contraceptive pill and injections, it is important to understand the link bet-ween the two. this study was aimed to evaluate the alteration in oxidative stress markers including sod, catalase and mad and to correlate it with obesity in females using contraceptives. methodology this comparative cross sectional study was the project of the university of lahore (uol), in collaboration with basic health unit (bhu) mudkey (periphery of kasur) from january to december 2013. the study population comprised of 51 married females of age ranged 25 to 40 years. research ethical committee of uol approved the study. healthy married females with reproductive age were included in the study. unmarried females, lactating, menopausal and females with any pelvic pathology were excluded. subjects with history of neurological disorders, metabolic diseases including hepatic disorders, diabetes mellitus and cancer that could influence their oxidative markers were also excluded from the study. thirty-one females either using combined oral contraceptive (coc) pills or progestin injections for a period of 9 months were enrolled, while 20 females of the same age group not using any type of contraceptives were recruited as control group. all participants were enrolled by purposive sampling technique from bhu, mudkey. informed consent was taken from each participant. obesity status was evaluated and compare among the females not using contraceptives (control group) and females using contraceptive. subjects were further subdivided into obese and non-obese groups based on bmi for comparison of stress markers and to find out the association between obesity and oxidative stress markers. all relevant information was recorded on predesign questionnaires. height in meters and weight in kg were estimated by stadiometer and weighing scale (zt 160 nsl) bmi was calculated by formula weight in kg/ height in m2. subjects having bmi > 25 kg/m2 were considered obese as per who guidelines for asians.7 blood samples (5ml) were drawn for estimation of stress markers including sod, catalase, glutathione and mda. serum was separated from blood samples by centrifugation within one hour of collection and stored at -70° c until assayed. sod was assayed by nitroblue tetrazolium (nbt) method by spectrophotometer. catalase and glutathione levels were also determined by spectrophotometer procedure. the mda levels were measured by thiobarbituric acid (tba) assay reaction with mda. statistical analysis: spss version 20 was used to analyze the data. continuous variables were expressed as mean ± sd (standard deviation), while categorical variables (obesity) were presented as frequency and percentages. normality of data was checked by shaprio wilk test. independent t-test was used to compare stress markers among obese and non-obese females. regression analysis was applied to show the association between independent variable (obesity) and dependent variables (oxidative stress markers). results of regression analysis were expressed as beta coefficient and standard error. p-value ≤ 0.05 was considered statistically significant. results this study was comprised of 51 females of mean aged 30.8±5.4 year. out of total 51 participants, 24 (47%) were obese having bmi > 25 kg/m2 and 27 (53%) were non-obese. of total population, 21 females were using progestin injections, while 10 were on low dose coc pills. twenty females were not using any type of contraceptive. in the females using contraceptives 16 (51.6%) were obese as compared to 8 (40%) of obese females who were not using contraceptives. current results reveal that sod levels were higher in obese group as compared to non-obese group, the difference was statistically significant (p-value 0.000). no significant differences were noted in obese and non-obese subjects with respect to catalase (p-value 0.35) and glutathione (p-value 0.9) concentrations. statistically significant difference was observed in mean mda concentration among the obese and non-obese females (p-value 0.04). mda was higher in obese subjects than in non-obese subjects (table1). scattered plot graph confirms the fauzia aitazaz et al j aziz fatm med den college january june 2020; vol. 2, no. 1 14 significant positive association between sod and obesity (figure 1). figure 1: scattered plot between mass index (bmi) and superoxide dismutase (sod) (n=51) bmi = body mass index, sod = superoxide dismutase table 1: comparison of mean scores among study groups (n=51) kilogram/meter2 (kg/m2), units/milliliter (u/ml), micromole/litter (µmol/l), p-value ≤ 0.05 was considered significant. regression analysis shows significant positive association of bmi with sod (p value 0.006) and mda (p value 0.000). however, catalase (p value 0.28) and glutathione (p value 0.85) were not significantly associated with bmi (table2). discussion current study was aimed to evaluate the oxidative stress by estimating stress markers and status of obesity in the females using contraceptive pills and injections. association between obesity and oxidant-antioxidant status in these females was also explored. sod, catalase and glutathione are crucial parameters of antioxidants defense system. glutathione is a potent antioxidant that is involved in protection of proteins required for nucleic acid synthesis and helps in repairing of dna.8 table 2: regression analysis between bmi and oxidative stress markers (n=51) oxidative stress markers beta coefficient (β) standard error p value superoxide dismutase (sod) 0.041 0.015 0.006* catalases (cat) 0.003 0.007 0.284 glutathione (gsh) 0.001 0.003 0.85 malondialdehyde (mda) 1.661 1.297 0.000* independent variable is body mass index (bmi), dependent variables are oxidative stress markers, p-value ≤0.05 was considered significant. generation of ros and resultant high levels of end product of lipid peroxidation mda with insufficient antioxidant enzymes reflect the oxidative stress.9 intense oxidative stress has harmful effects on cellular functions, intracellular signaling, gene regulation, apoptosis and results in cellular death.10 strong evidences are available showing that the females using oral as well as injectable contraceptives have positive effect on their bmi causing obesity.2 growing evidences also indicate that the white adipose tissues in obese subjects are associated with excess generation of ros including superoxide (o2 -) and h2o2, accompanied by augmented expression of nadph oxidase and decline in anti-oxidative enzymes that are required to resist ros mediated cellular damage.3 if oxidation by ros exceeds the antioxidants defense system, oxidative stress is generated.10 we found significant higher levels of mda in obese subjects and it was significantly associated with bmi, suggesting the presence of oxidative stress in these subjects. current result concerning positive association of mda with bmi is supported by study conducted in china.6 higher mda levels in obese subjects are also reported by researches conducted in various other regions of world including jordan and saudi arabia that justified our results.3,4 present study also found higher levels of anti-oxidant sod in obese subjects than non-obese subjects and was positively related with bmi. sod is believed to be the first line of antioxidant defense system. this finding is confirmed by the past study from jordan that documented similar relation.3 however, inconsistent results are documented by other studies conducted in stress markers obese females n(%) 24(47) non-obese females n(%) 27(53) p value mean ± sd mean ± sd body mass index (bmi) kg/m2 26.95 ± 1.50 20.85 ± 2.21 0.000* superoxide dismutase (sod) u/ml 0.84 ± 0.38 0.58 ± 0.39 0.02* catalase (cat) u/ml 2.75 ± 0.07 2.77 ± 0.09 0.35 glutathione (gsh) u/ml 0.42 ± 0.58 0.41 ± 0.07 0.9 malondialdehyde (mda) µmol/l 0.73 ± 0.47 0.55 ± 0.313 0.04* evaluation of oxidative stress markers j aziz fatm med den college january june 2020; vol. 2, no. 1 15 saudi arabia, and documenting decrease activity of sod in obese subjects.4 current study did not find any influence of obesity on catalase and glutathione. present results are in line with al-dalaeen et al who reported no impact of bmi on catalase and glutathione.3 while on the other hand, albuali et al reported decrease in glutathione levels in obese subjects.4 increase in mda but not increase in above mentioned antioxidant results in imbalance between oxidantantioxidant systems causing oxidative stress in obese subjects. increase in the first line of antioxidant defense sod in obese subjects of current study might be in the response to generation of oxidative stress induced by over production of ros and higher lipid peroxidation reflected by higher mad levels. activation of sod counteracts the effect of ros and protects cells from damaging effects of oxidants. current findings are justified by an h et al who reported the overproduction of ros and activation of the antioxidant defense system in obese subjects.6 contradictory to our results, das et al documented decrease activity of sod, glutathione and catalase along with higher mda levels and subsequent oxidative stress in obese population.9 limitations: the causality between bmi and oxidative stress could not be established due to cross sectional study design. due to small sample size the result cannot be generalized to whole female population. conclusion oxidative stress in obese is due to higher mda levels. sod is positively associated with bmi; however, catalase and glutathione are not affected by bmi. funding source: none. conflicts of interest: none. references 1. maffetone pb, rivera-dominguez i, laursen pb. overfat adults and children in developed countries: the public health importance of identifying excess body fat. front public health. 2017; 5:190.doi:10.3389/fpubh.2017.00190. 2. lopez lm, ramesh s, chen m, edelman a, otterness c, trussell j,et al. progestin only contraceptives: effects on weight. cochrane database syst rev. 2013; (7):cd008815. doi: 10.1002/14651858.cd008815.pub3. review. update in: cochrane database syst rev. 2016;8:cd008815 3. al-dalaeenam, al-domi ha. evaluation of oxidantantioxidant status in obese children and adolescents. pakistan j of nutr.2016; 15(10):942947.doi:10.3923/ pjn. 2016.942.947.url: https://scialert.net/abstract/?doi= pjn.2016.942.947 [cited on 2019 july 15]. 4. albuali wh. evaluation of oxidant-antioxidant status in overweight and morbidly obese saudi children.world j clin pediatr. 2014; 3 (1):6-13. doi: 10.5409/wjcp.v3.i1.6. 5. mohseni r, sadeghabadi za, goodarzi mt, teimouri m, nourbakhsh m, azar mr. evaluation of mn-superoxide dismutase and catalase gene expression in childhood obesity: its association with insulin resistance. j pediatr endocrinol metab. 2018; 31(7):727-732. doi:10.15 15/jpem-2017-0322 6. an h, du x, huang x, qi l, jia q, yin g et al. obesity, altered oxidative stress, and clinical correlates in chronic schizophrenia patients. transl psychiatry. 2018; 8(1):258. doi: 10.1038/s41398-018-0303-7. 7. jawed s, mannan n, qureshi ma. association of surfactant protein-d with obesity. j ayub med coll abb ottabad. 2016; 28(3):489-492 8. shazia q, mohammad zh, rahman t, shekhar hu. correlation of oxidative stress with serum trace element levels and antioxidant enzyme status in beta thalassemia major patients: a review of the literature. anemia.2012; 2012:articleid270923.doi:101155/2010/270923 http://downloads.hindawi.com/journals/anemia/2012/2709 23.pdf [cited on 2019 july 15]. 9. das p, biswas s, mukherjee s, bandyopadhyay sk. association of oxidative stress and obesity with insulin resistance in type 2 diabetes mellitus. mymensingh med j. 2016;25(1):148-152 10. youssef hmg, salem ht. oxidative stress parameters in patients with breast cancer before and after radiotherapy. egypt. j. rad. sci. applic. 2019; 32(2): 177-185.doi:10.2 1608/ejrsa.2019.15164.1079 fauzia aitazaz et al https://www.ncbi.nlm.nih.gov/pubmed/28791284 https://www.ncbi.nlm.nih.gov/pubmed/28791284 https://www.ncbi.nlm.nih.gov/pubmed/28791284 https://www.ncbi.nlm.nih.gov/pubmed/23821307 https://www.ncbi.nlm.nih.gov/pubmed/23821307 https://www.ncbi.nlm.nih.gov/pubmed/27567593 https://www.ncbi.nlm.nih.gov/pubmed/27567593 http://dx.doi.org/10.3923/pjn.2016.942.947 https://www.ncbi.nlm.nih.gov/pubmed/25254179 https://www.ncbi.nlm.nih.gov/pubmed/25254179 https://www.ncbi.nlm.nih.gov/pubmed/29953407 https://www.ncbi.nlm.nih.gov/pubmed/29953407 https://www.ncbi.nlm.nih.gov/pubmed/29953407 https://www.ncbi.nlm.nih.gov/pubmed/30498208 https://www.ncbi.nlm.nih.gov/pubmed/30498208 https://www.ncbi.nlm.nih.gov/pubmed/30498208 https://www.ncbi.nlm.nih.gov/pubmed/28712219 https://www.ncbi.nlm.nih.gov/pubmed/28712219 https://www.ncbi.nlm.nih.gov/pubmed/26931265 https://www.ncbi.nlm.nih.gov/pubmed/26931265 j aziz fatm med den college january june 2020; vol. 2, no. 1 16 author’s contribution: dr. fauzia aitazaz study design, data collection, manuscript writing, revising all intellectual contents and accountable for al research work. radhia khan manuscript writing, revising all intellectual contents and accountable for al research work. dr. samiullah khan statistical analysis, interpretation of results, manuscript writing, revising the final version and accountable for al research work. dr. zakia khan statistical analysis, interpretation of results, manuscript writing, revising the final version and accountable for al research work. received: 19 aug 2019, revised received: 10 oct 2019, accepted: 05 nov 2019 evaluation of oxidative stress markers july december 2019; vol. 1, no. 2 j aziz fatm med den clg 50 original article inter-arm blood pressure difference as an emergent risk for pre-hypertension javaria manzoor, muhammad absar alam, rooha tariq abstract objective: this study was aimed to determine the frequency of pre-hypertension and hypertension along with its association with inter-arm difference of blood pressure. methodology: it was a cross sectional study conducted at aziz fatimah medical and dental college faisalabad. students of age ranged 19-21 years were enrolled by convenience sampling technique for screening of prehypertension and hypertension. blood pressure was recorded from both arms by using sphygmomanometer and inter-arm differences were estimated. mean±sd for continuous variables, frequency and percentages for categorical variables and chi square for association between pre-hypertension, hypertension and inter-arm difference was analyzed by spss 21. results: study comprised of 100 students with mean age 19.79±1.18 years. of total 47% were females and 53% was male population. mean systolic (p value =0.0002*) and diastolic (p value =0.000*) blood pressure of the two arms were significantly different. of total population, 27% and 13% of population had pre-hypertension and hypertension respectively. mean systolic inter-arm difference was significantly higher among the hypertensive subjects as compared to pre-hypertensive subjects, (p value =0.0001*). no significant difference was noted with respect to diastolic inter-arm difference (p value =0.93). greater percentage of normotensive subjects have systolic inter-arm difference <10mmhg as compared to this most of the subjects with hypertension and pre-hypertension have systolic inter-arm difference of >15mmhg. significant association between hypertension and systolic interarm difference was noted (p value =0.025) conclusion: pre-hypertension and hypertension is prevalent among young adults. high systolic inter-arm difference was significantly associated with pre-hypertension and hypertension. keywords: diastolic blood pressure, hypertension, inter-arm differences, pre-hypertension. introduction burden of the pre-hypertension on health care system has consistently increased globally especially in developing countries. it is one of the key precursors for developing hypertension in young adults and subsequent cardiovascular disorders in later life.1 prevalence of pre-hypertension and hypertension in pakistan is reported as 55% and 18.9% respectively which is increasing at an alarming rate due to sedentary life styles, diet high in calories, low in fruits and ___________________________________________ dr. javaria manzoor (mbbs) demonstrator aziz fatimah medical and dental college, faisalabad dr. muhammad absar alam (mbbs, mrcp) assistant professor independent medical and dental college, faisalabad dr. rooha tariq (mbbs) demonstrator aziz fatimah medical and dental college, faisalabad correspondence: dr. javaria manzoor email: javaria.manzoor@gmail.com vegetables.2 hypertension has been considered as a silent killer and attributed to life threatening complications.3 pre-hypertension and subsequent hypertension is an independent risk factor for ischemic stroke, left ventricular hypertrophy and other cardiovascular events.4 most of the young adults remain undiagnosed and progress to severe consequences. early detection and management of hypertension are thus of extreme importance to reduce the rate of mortality and morbidity.5 it is evident that by identifying the pre-hypertensive and hypertensive subjects earlier can reduce the chances of progression to severe cardiovascular disorders by modifying life style. early treatment with antihypertensive medications can achieve better control in young adults within a shorter period as compared to older adults. 5 inter-arm difference (iad) of blood pressure has received increasing attention after finding its association with peripheral vascular disease and increasing cardiovascular morbidity.6 previous recent studies have reported that inter-arm systolic difference of mailto:javaria.manzoor@gmail.com july december 2019; vol. 1, no. 2 j aziz fatm med den clg 51 0 20 40 60 80 100 120 right arm left arm 111.67±12.5 119±14.25 79.6±9.32 82.97±9.32 m e a n b lo o d p re ss u re ( m m h g ) systolic blood pressure diastolic blood pressure >10mmhg predisposes to vascular diseases with reduced survival rate.6 the revised clinical guideline from the national institute of health and clinical excellence (nice) considers an inter-arm difference of <10mmhg systolic to be normal and a difference of >15mmhg to be associated with vascular diseases.7 due to the increasing prevalence of hypertension in young population, it is to be recommended by nice to estimate blood pressure bilaterally as routine part of hypertension assessment in primary care, which reduces the risk of misdiagnosis of hypertension .7 systolic iad can be useful in early screening of hypertension and cardiovascular diseases. the progression of pre-hypertension to hypertension can be avoided by healthy life style and dietary modifications4. this study was aimed to determine the frequency of pre-hypertension and hypertension along with its association with inter-arm difference of blood pressure. methodology this was cross-sectional study, conducted at aziz fatimah medical and dental college faisalabad during june to september 2019. study population comprised of 100 medical students of age ranged 19-21 years. ethical approval from the institutional ethical committee (iec) was obtained prior the study. medical students of 1st-2nd year mbbs were screened for prehypertension and hypertension selected by convenient sampling technique. subjects with known history of cardiovascular diseases were excluded from the study. informed consent was taken from each participant and confidentiality was assured. height in meters and weight in kilograms were recorded by stadiometer. (zt160) bmi was estimated by quetelet’s index: bmi =weight in kg/ height in m2.8 subjects were allowed to relax for 5 minutes and then the recording of blood pressure was carried out in a comfortable environment. blood pressure was assessed simultaneously in both arms. three readings were taken with 1 minute interval by using sphygmomanometer with appropriate sized cuff, with subject arm supported at heart level as recommended by american heart association (aha).9 average of three readings was recorded for estimation of iad. prior the recording of blood pressure, zero error of the apparatus was checked. systolic blood pressure was noted with the onset of clear korotkoff sounds and with the disappearance of these sounds, diastolic blood pressure was recorded. mercury level of the sphygmomanometer was observed in a direct line to avoid parallax error.9 interarm difference of systolic and diastolic blood pressure was calculated for further statistical analysis. all participants were categorized into three groups on the basis of their blood pressures i.e. normotensive, prehypertensive and hypertensive subjects. as per joint national committee guidelines (jnc guidelines): blood pressure <90/60 mmhg is considered low, blood pressure ranging 91/61 120/80 mmhg is normal. blood pressure ranging 121/81 139/89 mmhg is labeled as pre-hypertension and ≥140 mmhg systolic or ≥90 mmhg diastolic blood pressure is labeled as hypertension.3 inter-arm difference of blood pressure was categorized into <10 mmhg, 10-15 mmhg and >15 mmhg for analysis purpose. according to nice systolic iad blood pressure <10 mmhg is considered normal, >15mmhg of systolic iad blood pressure are risk for cardiovascular disorders and peripheral vascular diseases.7 statistical analysis of data was done on spss 21. continuous variables including systolic, diastolic blood pressures and iad are presented as means±sd. mean blood pressures between right and left arms were compared by paired student t-test. mean iad blood pressures among the normotensive, pre-hypertensive and hypertensive subjects were compared by anova. data is expressed as percentages for categorical variables like hypertension and pre-hypertension and various categories of systolic iad. chi-square (x2) test was used to evaluate association of hypertension and iad. results hundred medical students of both genders were screened for pre-hypertension and hypertension. figure 1: comparison of blood pressure between arms (n=100) p value ≤0.05 is considered as significant, systolic blood pressure p value = 0.0002* & diastolic blood pressure p value =0.000* mean±sd of age of the participant was 19.79±1.18 years. mean age, height in meters, weight in kg and bmi were 19.79±1.18, 1.70±0.08, 68.35±15.14 and javaria manzoor et al. july december 2019; vol. 1, no. 2 j aziz fatm med den clg 52 0 2 4 6 8 10 12 14 16 18 normotensive prehypertensive hypertensive 8.1±5.7 11.41±6.9 16.54±8.7 5.97±4.2 6.3±4.5 6.31±5.8 in te ra rm b lo o d p re ss u re d if fe re n ce ( m m h g ) iad systolic pressure iad diastolic pressure 23.44±3.71. significant differences were observed in systolic (p value =0.0002*) and diastolic (p value =0.000*) blood pressure of the two arms, figure 1. of total population, 60%, 27% and 13% were normotensive, pre-hypertensive and hypertensive subjects respectively. mean systolic iad was significantly higher among the hypertensive subjects followed by pre-hypertensive as compared to normotensive subjects (p value =0.0001*). no significant difference was noted with respect to diastolic iad (p value =0.93), figure 2. figure 2: inter-arm blood pressure difference among the study groups (n=100) iad, inter arm difference, p value ≤0.05 is considered as significant, iad systolic blood pressure, p value =0.0001*, iad diastolic blood pressure, p value =0.93 as we found the significant difference only in systolic iad among the three study groups, we analyzed its categories and we noted that greater percentage of normotensive subjects have systolic iad <10mmhg as compared to this most of the subjects with hypertension and pre-hypertension have systolic iad >15mmhg. chi-square shows that there is a significant association between hypertension and systolic iad, (p value =0.025*) table-1. table 1: inter-arm systolic difference (n=100) inter-arm difference clinical variables <10 mmhg n (%) 10-15 mmhg n (%) >15 mmhg n (%) p value prehypertension (n=27) 19 (70.4%) 2 (7.4%) 6 (22.2%) 0.025* hypertension (n= 13) 7 (53.8%) 1 (7.7%) 5 (38.5%) normotensive (n=60) 54 (90%) 1 (1.7%) 5 (8.3%) association was analyzed by x2 test. p value ≤0.05 is considered as significant. discussion present study highlights the significance of inter-arm difference in blood pressure and its association with hypertension. pre-hypertension and hypertension in young age group is an emerging common health issue worldwid.1 its prevalence is continuously raising due to adoption of sedentary and unhealthy life style and increasing trends towards obesity in youngsters.2 huge burden on health care system due to increased prevalence of hypertension and its consequences require serious consideration.9 there is need of early screening and identification of youngsters at high risk of pre-hypertension and hypertension to adopt proper possible preventive measures and management to prevent its detrimental consequences.9 evidences are available showing that subjects having systolic iad blood pressure greater than 15mmhg possess high risk for hypertension and subsequent cardiovascular diseases. the current study highlights the recent recommendations by nice that blood pressure should be measured in both arms to avoid the misdiagnosis of hypertension.7 this study was designed to screen the prehypertension and hypertension among the young adults and to elucidate its association with iad of blood pressure. we found that 27% and 13% of total study participants had pre-hypertension and hypertension respectively. previous study conducted in faisalabad is in agreement with current results as they found prehypertension in similar age group and reported that the 48% of obese youngsters in their study had prehypertension.9 another study conducted in lahore had reported pre-hypertension in 55% of young adults.10 study conducted in six coastal villages of india by kini s and his colleagues also supported present results and documented 45.2% of young subjects with prehypertension in their study.11 our results are also consistent with study conducted in saudi arabia that reported 14.6% and 29.2% prevalence of hypertension and pre-hypertension among the age group 15-24.5 current study found significantly higher systolic iad in hypertensive subjects followed by pre-hypertensive in contrast to subjects with normal blood pressure (p value =0.01*). this is confirmed by sharma b and his colleague, who reported significant higher mean systolic inter-arm blood pressure difference among patients with cardiovascular diseases in contrast to normal subjects.12 present study did not find significantly higher diastolic iad in hypertensive as compared to subjects with normal blood pressure (p value= 0.93). on contrary to this, mehlsen j study had reported the significant increase in systolic as well as inter-arm difference & pre-hypertension july december 2019; vol. 1, no. 2 j aziz fatm med den clg 53 diastolic inter-arm difference in hypertensive subjects.13 a report of the american college of cardiology/american heart association task force on clinical practice guidelines also supports the current study as they documented the association of higher systolic blood pressure with cardiovascular diseases independently of diastolic blood pressure. on contrary to this diastolic blood pressure has not been associated with cardiovascular disorders after adjustment for systolic blood pressure.14 current study found that 90% subjects with normal blood pressure had ≤10 mmhg systolic iad, in contrast to this only 70% and 53% of pre-hypertensive and hypertensive subjects had ≤10 mmhg iad. we also found that 38.5% and 22.2 % of hypertensive and pre-hypertensive subjects have >15mmhg of iad systolic blood pressure as compared to this only 8.3% of normotensive were fell in this category. the current findings may be justified with the report of canepa et al who documented that systolic iad >10mmhg could result in increased arterial stiffness which leads to development of hypertension and cardiovascular disorders.15 the similar findings were observed in the study of kim and his colleagues.4 present study also found significant association between raised systolic iad and hypertension, this is supported by su hm et al, who also documented association of systolic iad >10mmhg with hypertension and obesity.16 future studies on a larger scale are required for early screening of young adults at risk of hypertension and to evaluate association between inter-arm blood pressure difference and hypertension. this study emphasizes the need for continuous efforts in early screening, prevention and control of hypertension in young population. limitations: small sample size is the limitation of the study which may not represent the whole population. we cannot establish the causal association in this study due to its cross section design. conclusion pre-hypertension and hypertension is prevalent among young adults and are significantly associated with increase in systolic inter-arm difference. recommendation: screening of pre-hypertension and hypertension should be arranged in colleges and universities at national level to identify the young students having this ailment. bilateral blood pressure should be measured during the routine medical checkups for early detection of subjects at risk of hypertension. funding source: none. conflicts of interest: none. references 1. tripathy jp, thakur js, jeet g, chawla s, jain s. alarmingly high prevalence of hypertension and prehypertension in north india-results from a large crosssectional steps survey. plos one. 2017; 12(12): doi: 10.1371/ journal. pone.0188619. 2. peltzer k, pengpid s, sychareun v, ferrer ajg, low wy, huu tn, et al. pre-hypertension and psychosocial risk factors among university students in asean countries. bmc cardiovasc disord. 2017; 17 (1):230. doi: 10.1186/s12872-017-0666-3. 3. kayce bell, june twiggs, polin b r. hypertension: the silent killer: updated jnc-8 guideline recommendations. alabama pharmacy association; 2015 june.4p.report no.: 0178-0000-15-104-h01-p. 4. kim j, song tj, song d, lee hs, nam cm, nam hs, et al. inter-arm blood pressure difference and mortality in patients with acute ischemic stroke. neurology. 2013; 80(16): 1457-1464. doi: 10.1212/ wnl. 0b013e 31828 cf87c. 5. alwabel ah, almufadhi ma, alayed fm, alorain ay, alobaysi hm, alalwi rm. assessment of hypertension and its associated risk factors among medical students in qassim university. saudi j kidney dis transpl. 2018; 29(5):1100-1108. doi: 10.4103/1319-2442. 243959. 6. kranenburg g, spiering w, de jong pa, kappelle lj, de borst gj, cramer mj, et al. inter-arm systolic blood pressure differences, relations with future vascular events and mortality in patients with and without manifest vascular disease. int j cardiol. 2017; 244: 271-276. doi: 10.1016/j.ijcard. 2017. 06.044. 7. national institute for health and clinical excellence, hypertension in adults: diagnosis and management nice guideline [ng136] published date: august 2019. 8. kaur m. correlation between body mass index and blood pressure in adolescents. pak j physiol. 2016; 12(1): 47–50. 9. jawed s, zia s, tariq s. frequency of different blood groups and its association with bmi and blood pressure among the female medical students of faisalabad. j pak med assoc. 2017; 67(8):1132-1137. 10. hanan r, shafi mw, anwar s, nawaz n. hypertension and pre-hypertension with associated risk factors among mbbs students of shalamar medical and dental college, lahore. ann king edward med uni.2017; 23(4):445-450. doi:http: //dx.doi. org/10.21649/journal.akemu/2017/23.4. 445.450. 11. kini s, kamath vg, kulkarni mm, kamath a, shivalli s. pre-hypertension among young adults (20-30 years) in coastal villages of udupi district in southern india: an alarming scenario. plos one. 2016; 11(4): e0154538. doi: 10.1371/journal.pone.0154538. 12. sharma b, ramawat p. prevalence of inter-arm blood pressure difference among clinical out-patients. int j health sci (qassim). 2016; 10(2):229-237. javaria manzoor et al. https://www.ncbi.nlm.nih.gov/pubmed/?term=alwabel%20ah%5bauthor%5d&cauthor=true&cauthor_uid=30381506 https://www.ncbi.nlm.nih.gov/pubmed/?term=almufadhi%20ma%5bauthor%5d&cauthor=true&cauthor_uid=30381506 https://www.ncbi.nlm.nih.gov/pubmed/?term=alayed%20fm%5bauthor%5d&cauthor=true&cauthor_uid=30381506 https://www.ncbi.nlm.nih.gov/pubmed/?term=aloraini%20ay%5bauthor%5d&cauthor=true&cauthor_uid=30381506 https://www.ncbi.nlm.nih.gov/pubmed/?term=aloraini%20ay%5bauthor%5d&cauthor=true&cauthor_uid=30381506 https://www.ncbi.nlm.nih.gov/pubmed/?term=alobaysi%20hm%5bauthor%5d&cauthor=true&cauthor_uid=30381506 https://www.ncbi.nlm.nih.gov/pubmed/?term=alalwi%20rm%5bauthor%5d&cauthor=true&cauthor_uid=30381506 https://www.ncbi.nlm.nih.gov/pubmed/?term=alwabel%20ah%5bauthor%5d&cauthor=true&cauthor_uid=30381506 july december 2019; vol. 1, no. 2 j aziz fatm med den clg 54 13. mehlsen j, wiinberg n. inter-arm difference in blood pressure: reproducibility and association with peripheral vascular disease. int j vasc med. article2014; id 841542, http://dx.doi.org/ 10.1155/2014/841542. 14. whelton pk, carey rm, aronow ws, casey de jr, collins kj, dennison himmelfarb c et al. 2017 acc/aha/aapa/abc/acpm/ags/apha/ash/aspc/ nma /pcna guideline for the prevention, detection, evaluation, and management of high blood pressure in adults: a report of the american college of cardiology/american heart association task force on clinical practice guidelines [published correction appears in hypertension. hypertension. 2018; 71 (6):1269-1324. doi: 10.1161/hyp. 0000000000000066. 15. canepa m, milanesch y, ameri p, al ghatrif m, leoncini g, spallarossa p, et al. relationship between inter-arm difference in systolic blood pressure and arterial stiffness in community-dwelling older adults. j clin hypertens (greenwich). 2013; 15(12):880–887. 16. su hm, lin th, hsu pc, chu cy, lee wh, chen sc, et al. association of inter-arm systolic blood pressure difference with atherosclerosis and left ventricular hypertrophy. plos one. 2012; 7(8):e41173. inter-arm difference & pre-hypertension author’s contribution: dr. javaria manzoor study design and data collection, manuscript writing, formulation of tables and graphs and approval. dr. rooha tariq data collection, manuscript writing and approval. accountable for the integrity of the data. dr. muhammad absar alam data analysis and interpretation, article review and approval. http://dx.doi.org/%2010.1155/2014/841542 july december 2019; vol. 1, no. 2 j aziz fatm med den clg 55 original article professional quality of life and its association with work experience and income among healthcare workers nirmeen maroof, mirza zeeshan sikandar, haleema nawaz, syed imran ali shah abstract objective: the objective of the study is to assess job satisfaction between groups of healthcare workers based on their work experience and monthly salary. methodology: healthcare workers (n=81) including clinicians, nurses and medical teachers were recruited from a private medical institute at lahore. job satisfaction survey (jss) and professional quality of life (proqol) scale including its component scales of compassion satisfaction (cs), burnout (bo) and secondary traumatic stress (sts) were used to determine aspects of vocational quality of life and satisfaction. kruskal-wallis test was used to assess group differences. spearman correlational analysis was done to assess correlation between income, work experience and job satisfaction. results: significantly higher professional satisfaction, lower burnout and stress scores were observed in experienced healthcare workers as compared to less-experienced ones (p value =0.039* for jss, p value =0.011* for cs, p value =0.055* for bo and p value =0.027* for sts). significantly higher satisfaction scores were found in workers with higher monthly income as compared to those with lower monthly salary (p value =0.006* for jss and p value =0.032* for cs). significant positive correlation was observed between healthcare workers’ job satisfaction and their experience and monthly salary. conclusion: more experience at work is particularly associated with lower burnout and reduced occupational stress. keywords: job satisfaction, healthcare, burnout, traumatic stress. introduction job satisfaction is the level of an employee contentment with his occupation.1 the perception that working individuals have, role in an organization directly influences their level of job satisfaction.2 job satisfaction is optimistic feeling of job, represents a collective positive or negative feelings towards their work.3 employee satisfaction is influenced by a variety of modifiable factors which include, but not only limited to remuneration, recognition of accomplishments, appreciation for one’s job. employee satisfaction is influenced by a variety of efforts, duty hours, relationship with coworkers, ____________________________________________________________ nirmeen maroof 4th year mbbs student central park medical college, lahore mirza zeeshan sikandar 4th year mbbs student central park medical college, lahore haleema nawaz 4th year mbbs student central park medical college, lahore dr. syed imran ali shah (mbbs, mphil, phd) professor central park medical college, lahore correspondence: dr. syed imran ali shah email: s.shah10@alumini.imperial.ac.uk opportunities for professional development and job security.3 compassion satisfaction (cs) reflects the positive outcome of working with challenging environment.4 several non-modifiable factors such as age and gender have also been linked to job satisfaction.4 provision of optimum emergency healthcare to the society is pivotal. healthcare professionals have very challenging jobs with prolong and sometimes awkward working hours. they are at an increased risk for traumatic experiences. moreover, they are themselves vulnerable to a variety of effects, including depression, anxiety, intrusive imagery, cognitive shifts and problems in their social relationship at their work place which can negatively affect their professional satisfaction. such negative consequences have been described in terms of compassion fatigue (cf).5 burnout (bo) is emotional and mental exhaustion leading to lack of personal accomplishment caused by long-term involvement in emotionally challenging circumstances.6 the assessment of job satisfaction is important as high job satisfaction is associated with enhanced productivity and lower employee turnover rates. while low job satisfaction results in an increase in absenteeism and decreased employee efficiency. 6 mailto:s.shah10@alumini.imperial.ac.uk july december 2019; vol. 1, no. 2 j aziz fatm med den clg 56 apart from doctors, health care workers include nurses, paramedics, lab assistants and instructors, are an essential pre-requisite for smooth functioning of any healthcare system.6 in low income countries like pakistan, bo and cf are emergent issues among the nursing staff. it is due to the low incentives and remuneration, longer working hours with work burden, stressful environment and lack of appreciation. this ultimately leads to reduced work capacity, depersonalization, cynicism and finally dissatisfaction of their job. it is very difficult to retain these caregivers on their job in pakistan and our country faced severe shortage of health care providers.7,8 there is need to optimize the working environment and health of healthcare professionals to prevent the negative impact on staff and impaired work capacity for better provision of health care services for patients.6,9 the healthcare delivery system in the private sector is considered to have better working conditions than the public sector, however, there is no indication that this leads to a higher level of job satisfaction in healthcare professionals working in private set-ups.9,10 job satisfaction has been investigated to some extent in the government sector but no substantive data from the private sector is available at present.11 numerous studies have evaluated patients’ satisfaction in terms of the medical care they receive at hospitals but professional satisfaction of healthcare workers has not been studied that extensively, especially in pakistan, where there is a considerable shortfall of adequately skilled human resource in healthcare services. it is imperative to assess the quality of life of health professionals in term of bo, cf and cs. this study investigated the association of professional satisfaction and quality of life with income and work experience of healthcare professionals working at a local tertiary care hospital in the private setting. methodology this cross-sectional study was conducted at private medical institute of lahore from june 2018 to december 2018. the study period included time to develop the proposal and associated documents, obtaining ethical approval, recruitment for the study, data input and analysis, review of the analysed data and write-up of the manuscript. the study was approved by the institutional research committee. the study population comprised of 81 healthcare workers. employees from medical institute were recruited using non-random convenience sampling. the sample size for this pilot exploratory study was calculated based on published data, in order to yield statistical power with level of significance set at ≤ 0.05. physicians, nurses and medical teachers were included in the study while medical lab personnel, surgical technicians and general duty assistants were excluded from the study. participants provided written informed consent before enrolment. the study population was segregated into groups based on their work experience and monthly remuneration. the rationale behind this grouping was to see whether experience or salary affect the outcomes of professional satisfaction. grouping by work experience included: group 1 with work experience <1year, group 2 with work experience between 1 to 5 years, group 3 with work experience of 5 to 10 years and group 4 with work experience >10 years. grouping by monthly salary included: group a with monthly salary <rs. 25,000/-, group b with a monthly salary between rs. 25,000/to rs. 50,000/-, group c with a monthly salary between rs.50,001/to rs.100,000/and group d with a monthly salary of >rs. 100,000/-. the data was collected by administering two validated self-report questionnaires namely the professional quality of life (proqol) scale and the job satisfaction survey (jss). these two instruments were used to determine vocational quality of life and satisfaction, respectively. professional quality of life (proqol) scale is 30 item self-report measures of the positive and negative effects of working comprised of 5 pointed likert scale (1=never, 2=rarely, 3=sometimes, 4=often & 5=very often).12 it was comprised of three components including compassion satisfaction (cs) and compassion fatigue (cf). cf further comprised of two elements, burnout (bo) and secondary traumatic stress (sts). scoring requires summing the item responses for each 10-item subscale, and higher scores indicate higher levels of compassion satisfaction, compassion fatigue, and burnout.13 job satisfaction survey (jss) structured survey questionnaires were also comprised of 30 items with yes and no options. each positively stated statement score 2 points for that researcher answered positively. points ranging from 50-60 were categorized in great satisfaction while point from 1-19 were taken as dissatisfaction.14 the questionnaires used were in the english language, thus only those healthcare workers who were well versed in the english language were included in the study. nirmeen maroof et al. july december 2019; vol. 1, no. 2 j aziz fatm med den clg 57 results the mean age of the participants was 31.88±10.15 years. grouping by work experience revealed significantly higher scores on jss and cs component of proqol (p value =0.039* for jss and p value =0.011* for cs) in experienced workers as compared to less experienced ones, reflecting a positive association between work experience and satisfaction (table 1). significant difference was also observed between groups on the bo and sts components of proqol (p value =0.055* for bo and p value =0.027* for sts), indicating lower burnout and professional stress in experienced healthcare workers as compared to newcomers (table 1). table 1. comparison of scores on jss and components of proqol between groups based on work experience (n=81) parameters group 1 (n=20) (median + iqr) group 2 (n=39) (median + iqr) group 3 (n=8) (median + iqr) group 4 (n=14) (median + iqr) p value jss 126.50 + 27.00 137.50 + 21.0 149.00 + 37.0 152.50 + 33.0 0.039* cs 36.00 + 12.0 39.00 + 12.0 42.50 + 7.0 42.50 + 8.0 0.011* bo 26.00 + 9.0 24.00 + 7.0 22.00 + 14.0 21.50 + 6.0 0.005* sts 27.00 + 13.0 23.00 + 7.0 21.50 + 5.0 25.00 + 13.0 0.027* *p ≤0.05 was taken as significant. assessment of groups based on monthly salary revealed significantly higher jss and cs scores in groups c and d as compared to groups a and b (p value =0.006* for jss and p value =0.032* for cs), reflecting increased professional satisfaction in healthcare workers with higher income as compared to those with lower income (table 2). no significant difference was observed between groups on bo and sts scores (p value =0.058 for bo and p value =0.205 for sts), although lower bo scores in higher salaried healthcare workers as compared to lower salaried ones were approaching the set level of statistical significance, suggesting higher pay to be associated with reduced professional fatigue (table 2). significant positive correlation was seen between monthly salary and jss (spearman’s r=0.351, p value =0.001). similarly, there was significant positive correlation between work experience and jss (spearman’s r= 0.299, p value =0.007*). table 2. comparison of scores on jss and components of proqol between groups based on monthly salary (n=81) parameters group a (n=7) (median + iqr) group b (n=28) (median + iqr) group c (n=30) (median + iqr) group d (n=16) (median + iqr) p value jss 122.00 + 23.0 131.00 + 30.0 144.00 + 20.0 147.00 + 32.0 0.006* css 31.00 + 17.0 37.50 + 10.0 41.00 + 8.0 40.50 + 8.0 0.032* bo 26.00 + 4.0 25.50 + 8.0 23.50 + 8.0 22.00 + 6.0 0.058 sts 23.00 + 9.0 26.00 + 12.0 23.30 + 7.0 24.00 + 7.0 0.205 *p ≤0.05 was taken as significant discussion the present findings reflect greater degree of job satisfaction and professional quality of life in healthcare professionals with higher work experience and better salary packages in comparison with those less work experience and lower income. the improved quality of life of healthcare workers as indicated by the low burnout and secondary traumatic stress was particularly associated with professional experience. bhatnagar et al. have shown previously that job satisfaction and the worker’s morale are correlated such that a greater the job satisfaction allows professionals to better utilize and enhance their creativity, planning and management skills, thereby improving their overall productivity.11 in accordance with our findings, an earlier study by garcía et al. showed that job satisfaction in healthcare professionals increases with age and experience. the relative lack of satisfaction in young healthcare workers was due to their desire of learning.15 results from a recent study in chinese doctors revealed low job with work-family conflict being found to have a negative impact and healthy doctor-patient relationship being shown to have a positive impact on job satisfaction.16 another recent study in china demonstrated that gender, age, marital status, educational attainment, professional title, and seniority affect job satisfaction in doctors.17 a sudanese study reported dissatisfaction in more than half of the doctors surveyed with working conditions, lack of training, inadequate compensation, excessive workload highlighted as the major factors contributing to the low job satisfaction.18 these aforementioned studies have quality of life among healthcare workers july december 2019; vol. 1, no. 2 j aziz fatm med den clg 58 highlighted varied factors influencing job satisfaction and professional qol of healthcare workers, some of which are dissimilar to our findings possibly due to non-uniformity of the administered questionnaires. in the current study, lower satisfaction scores and higher fatigue scores were seen in workers with less experience and low income. current finding are also justified by similar documentation from islamabad by bahalkani ha, who reported poor salaries are attributed to key cause of job dissatisfaction.1 these results are consistent with those of chen et al. who reported that strict working hours and lower income lead to dissatisfaction in healthcare professionals, particularly young doctors and paramedical staff.19 on contrary to current results, study conducted in lahore by naz s reported high burnout scores and low on qol in old and experienced nurses.7 studies in various healthcare set-ups worldwide have shown more dissatisfaction at work and professional burnout in junior, less experienced and early career staff members with invariably lower salaries as compared to their senior, experienced and more accomplished colleagues. low salary packages, long working hours, less chances for promotion and heavy workload are some of the salient factors that have been highlighted in previous studies to contribute to reduced job satisfaction and elevated stress health professionals.20, 22 limitations: study is limited by participation of a select group of healthcare professionals from a single center which hampers the general applicability of these findings. further, the grouping based on monthly salary is likely to have clustered nurses and medical teachers in the low salary bracket groups while consultant physicians are likely to have been included in the higher salary bracket groups, thus adding the confounding factor of profession which thereby further limits the robustness of the observed results. limitations need to be addressed in a larger multicenter study, preferably involving public sector as well as private sector health organizations to gather inferences that may eventually influence policy shifts to enhance job satisfaction and professional qol in healthcare workers. conclusion good salary packages and higher work experience have a positive impact on the professional satisfaction and quality of life of healthcare workers. recommendation: an effective organizational management policy should include strategies to improve the job satisfaction of lower income and less experienced healthcare workers to enhance their efficiency at work along with their personal and professional growth. funding source: none. conflicts of interest: none. references 1. bahalkani ha, kumar r, lakho ar, mahar b, mazhar sb, majeed a. job satisfaction in nurses working in tertiary level health care settings of islamabad, pakistan. j ayub med coll abbottabad. 2011; 23(3), 130-133. 2. anton c. the impact of role stress on workers' behavior through job satisfaction and organizational commitment. int j psychol 2009; 44(3):187-194. 3. naz s, sharma h. job satisfaction among different working organizations: a literature. review rjssm.2017; 7(6) :2937 4. cetrano g, tedeschi f, rabbi l, gosetti g, lora a, lamonaca d, manthorpe j, amaddeo how are compassion fatigue, burnout, and compassion satisfaction affected by quality of working life? findings from a survey of mental health staff in italy. bmc health serv res. 2017; 17(1):755. doi: 10.1186/s12913-017-2726 5. rossi a, cetrano g, pertile r, rabbi l, donisi v, grigoletti l, et al . burnout, compassion fatigue and compassion satisfaction among staff in community-based mental health services. psychiatry res. 2012; 200(2-3):933-938. doi: 10.1016/j.psychres.2012.07.029. e 6. baruah a, das s, dutta a, das b, sharma t, hazarika m. degree and factors of burnout among emergency healthcare workers in india. int j sci res (ahmedabad). 2019; 8(4): 41-45. doi: 10.15373/ 22778179 7. naz s, hashmi am, asif a. burnout and quality of life in nurses of a tertiary care hospital in pakistan. j pak med assoc. 2016;66(5):532-536 8. parveen s. acute shortage of nursing professional in pakistan. south american journal of nursing. 2016; special edition: 1-6. doi: 10.21522/tijnr.2015.02.01.art 02 9. khalid f, abbasi an. challenges faced by pakistani healthcare system: clinician's perspective. j coll physicians surg pak. 2018 dec; 28(12):899-901. doi: 10.29271/ jcpsp. 2018.12.899. 10. hamad n, alamgir, batool, ss, shabiralyani g, iqbal n. satisfaction with healthcare services provided in public hospitals of southern punjab, pakistan: study of district head quarter hospitals. j biol agri healthcare. 2015; 5(9):134-139. 11. bhatnagar k, srivastava k. job satisfaction in healthcare organizations. ind psychiatry j. 2012;21 (1):75-78. 12. professional quality of life. (proqol) scale. https://www.proqol.org/uploads/proqol_5_english_sel f-score_3-2012.pdf nirmeen maroof et al. https://www.ncbi.nlm.nih.gov/pubmed/29162095 https://www.ncbi.nlm.nih.gov/pubmed/29162095 https://www.ncbi.nlm.nih.gov/pubmed/29162095 https://www.ncbi.nlm.nih.gov/pubmed/29162095 https://www.ncbi.nlm.nih.gov/pubmed/31069180 https://www.ncbi.nlm.nih.gov/pubmed/31069180 https://www.ncbi.nlm.nih.gov/pubmed/30501822 https://www.proqol.org/uploads/proqol_5_english_self-score_3-2012.pdf https://www.proqol.org/uploads/proqol_5_english_self-score_3-2012.pdf july december 2019; vol. 1, no. 2 j aziz fatm med den clg 59 13. duarte j. professional quality of life in nurses: contribution for the validation of the portuguese version of the professional quality of life scale-5 (proqol-5). análise psicológica (2017), 4 (xxxv): 529-542. doi: 10.14417/ap.1260 14. job satisfaction survey https://www.examples.com/ business/job-satisfaction-survey.html 15. garcía cc, solano-ruíz mc, martínez-roche me, gómez-garcía ci. job satisfaction among health care workers: the role of gender and age. rev latino-am enfermagem.2013; 21(6):1314-1320. 16. deng s, yang n, li s, wang w, yan h, li h. doctors’ job satisfaction and its relationships with doctor-patient relationship and work-family conflict in china: a structural equation modeling. inquiry. 2018; 55:0046958018790831. 17. yu x, zheng m, cheng x, xu b, tao z, ding j, zhang k, jin h. job satisfaction among doctors from jiangsu province in china. med sci monit. 2018; 24:7162-169. 18. suliman aa, eltom m, elmadhoun wm, noor sk, almobarak ao, osman mm, awadalla h, ahmed mh. factors affecting job satisfaction among junior doctors working at teaching hospitals in river nile state, sudan. j public health emerg 2017; 1:79. 19. chen ah, jaafar sn, noor ar. comparison of job satisfaction among eight health care professions in private (non-government) settings. malays j med sci. 2012; 19(2): 19-26. 20. gouzou m, karanikola m, lemonidou c, papathanassoglou e, giannakopoulou m. measuring professional satisfaction and nursing workload among nursing staff at a greek coronary care unit. rev esc enferm usp. 2015; 49:15-21. doi: 10.1590/s00806234201500000003. 21. lu y, hu xm, huang xl, zhuang xd, guo p, feng lf, et al. job satisfaction and associated factors among healthcare staff: a cross-sectional study in guangdong province, china. bmj open. 2016; 6:e 011388. doi: 10.1136/bmjopen-2016-011388 22. sanchez-piedra ca, jaruseviciene l, prado-galbarro fj, liseckiene i, sánchez-alonso f, pérez sg, et al. factors associated with professional satisfaction in primary care: results from eu prime care project. eur j gen prac. 2017; 23(1):114-120. doi: 10.1080/ 13814788.2017.1305350. author’s contribution: nirmeen maroof study design, data collection and manuscript writing. mirza zeeshan sikandar study design, data collection and manuscript writing. haleema nawaz study design, data collection and manuscript writing. dr. syed imran ali shah concept of the study, data analysis and interpretation, manuscript writing and approval. all authors are equally accountable for the integrity of the data. quality of life among healthcare workers j aziz fatm med den college january – june 2021; vol. 3, no. 1 1 capacity building of editors of by higher education commission of pakistan is commendable initiative shireen jawed, benash altaf, farah amir ali numerous biomedical journals are currently published in pakistan and recognized by various regulatory bodies. out of these renowned medical journals, only three of them meet the criteria of international ranking of medical journals and earned the impact factors (if), which reflects the high number of citations of their publications. these journals include the pakistan journal of medical sciences (pjms), journal of pakistan medical association (jpma) and journal of college of physicians & surgeons pakistan(jcpsp).1 other pakistani medical journals are also doing their best efforts for uplifting their journals by improving the standard of publications and shortcomings. on the other hand, those who failed to improve the quality of journals have been derecognized by higher education commission (hec). there are so many causes of the failure of these journals.2 the most important reason being the inexperienced and untrained medical editors who though very enthusiastic for bearing additional burden of difficult unrewarding task. lack of guidance, knowledge, proper training, mentoring and limited financial revenue are also the factors contributing for a medical journal failure to reach the target set by hec. moreover, editors also experience the difficulty finding the proper subject specific expert reviewer in order to improve the manuscript intellectual content. in the same way, authors are also crucially important who are responsible for the manuscript but usually fails to comply with the cope guidelines for author. professionalism, following transparent policies, functional editorial boards and experienced reviewers helps in improving the standards of medical journals, reducing the pressure on the medical editors of reputable journals. hence, professional trainings are needed to improve the multidisciplinary domains of medical journalism for improving the quality and authenticity of the published work.3 in this regard, efforts of higher education commission pakistan (hec) are commendable for improving the standards of research journals and promoting professionalism in scientific editing through edification correspondence: dr. shireen jawed email: journal.editor@afmdc.edu.pk capacity building, mentoring and financial support of research journals. hec has set the new criteria to raise the quality of national research journals to meet the international standards. for this purpose, hec has promulgated revised journal recognition policies for the provision of a transparent system for accreditation. moreover, hec has been extending financial assistance to its recognized journals in numerous disciplines including medical sciences to support and overwhelmed their financial problems, which is creditable.2 hec has introduced an online system entitled “hec journal recognition system (hjrs)”for accreditation of journals. for assuring effective productivity and quality of journals they are evaluated based on six international benchmark matrices instead of using a single measure of journal impact factor depending on journal citation report (jcr).4 these matrices including eigen factor (ef), article influence (aif), h index, citation per doc, scimago, journal rank (sjr) and source normalized index per paper (snip). using these matrics, journal prestige index (jpi) is computed for categorization of research journals into w, x, and y categories.5 strengthening the capacities of authors, editors, as well as reviewers are mandatory for uplifting the research journals. hec is making persistent efforts for facilitating and training all stakeholders for enhancing knowledge and skills to address the root issues of problems, thereby ensuring the lasting results. hec in collaboration with local and international organizations is also been arranging several meetings, studios and webinars for editorial guidance, that is helping the editors of national research journals, trying to bring them up to the international levels. to endeavor this goal, the research and development department (r&d) of hec has conducted an online comprehensive series of capacity building program for the editors of research journals.6 these sessions were quite informative and covering all the required aspects including publication processing, peer review, editorial workflow and responsibilities of the editorial team. advantages of various tools like turnitin ithenticate for checking plagiarism and the use of publon for searching international reviewers for provision of constructive review and standard articles. all key points were discussed in these valuable sessions. furthermore, editors were guided about prerequisites and procedures for indexing with various editorial https://hjrs.hec.gov.pk/ j aziz fatm med den college january – june 2021; vol. 3, no. 1 2 international databases like a directory of open access journals (doaj), web of science and scopus for better visibility.the sessions about requirements of antipredatory agencies like the conduct of publication ethic (cope) was helpful and informative for making the individual journal new policies according to guidelines. dealing with authorship issue and any type of publication misconduct including plagiarism, falsification, and fabrication remained the part of discussion. the session concerning guidance about how to register with cope and how to avoid enlistment in beall’s list and cabell's predatory reports were also prove helpful for editors. points for avoidance for removal from doaj list and other data bases has been discussed in sessions. the orientation of the hjr system was also part of these sessions. session on use of open journal system for transparent handlings of an article and to improve the visibility of published research articles was also helpful and informative. hence all the session being arranged by r&d department were helpful in capacity building of editors.6 hopefully, efforts of the r&d team under the supervision of director dr. muhammad tahir ali shah in capacity building of the entire editorial team of national research journals will be fruitful and plays a key role in the flourishing of these medical journals, ensuring the publication of the best quality research work up to the international standards. our request in this aspect to hec is to provide opportunity to recognize the newly launched medical journals so that they get motivated to further enhance the quality of their journals based on laid down policies of hec. once again we are thankful to hec for its facilitation provided in form of capacity building which truly helped us to improve the quality of our journal. conflict of interest: none references 1. jawaid sa, jawaid m. impact factor is off the ventilator: survives and is thriving. pak j med sci. 2018; 34(6): 1317 1319doi:10.12669/pjms.346.16652 2. jawaid sa, jawaid m. revised publication policies by higher education commission for health science journals. pak j med sci.2020;36(2):13.doi:10.12669/pjms.36.2.2133. 3. jawaid sa, jawaid m. professional competencies required for editors of biomedical journals. pak j med sci. 2017 ;33(5):10501052.doi:10.12669/pjms.335.13967 4. hec journal recognition system. https: //hjrs.hec.gov.pk/ index php?r=site%2fabout [ cited on: feb16,2021] 5. hec journal recognition system. https://hjrs.hec.gov.pk/ [cited on : feb 17,2021] 6. research section and publication division. capacity building program me for the year 2020-21. .https ://hec. gov.pk /english/hec nnouncements/documents/brochure-research journals pdf [ cited on: feb 17,2021] shireen jawed et al, https://www.ncbi.nlm.nih.gov/pubmed/?term=jawaid%20sa%5bauthor%5d&cauthor=true&cauthor_uid=30559777 https://www.ncbi.nlm.nih.gov/pubmed/?term=jawaid%20m%5bauthor%5d&cauthor=true&cauthor_uid=30559777 https://www.ncbi.nlm.nih.gov/pubmed/30559777 https://doi.org/10.12669/pjms.335.13967 https://hjrs.hec.gov.pk/index.php?r=site%2fabout https://hjrs.hec.gov.pk/index.php?r=site%2fabout https://hjrs.hec.gov.pk/ journal.cdr original article impact of environmental tobacco smoke on pulmonary functions of females sadaf zia, hamid shafiq, fauzia jamshed, rana muhammad tahir salam abstract background:environmental tobacco smoke (ets) or passive smoking has an emerging burden on the society thus affecting the quality of individual's life. according to world health organization ets is referred to the involuntary inhalation of burning tobacco products emitted from the smoking devices. more than 4000 harmful compounds including carcinogens are emitted from burning cigarettes and cigars etc, which are extremely harmful for human health. pakistan has high tobacco consumption. due to this reason women and children are frequently exposed to indoor ets. subjects with exposure to ets have same ill effects as light active smokers. aim: to evaluate the lung functions of passive smokers and to compare with non-smokers of the same age and social background. methods: the study was conducted in a private hospital of faisalabad. 250 female subjects aged 1545 years were included in the study. data was collected by specially designed structured proforma and lung function tests were performed by spirometry. data was analyzed by using spss 20 version. p value ≤ 0.05 was taken as significant. results: 250 females participated in study. 61.2 % of total study population was exposed to tobacco smoking. out of total 250 subjects, 155(62%) had undiagnosed airway obstruction. fev1, fvc and fev1/ fvc ratio were lower in passive smokers as compared to nonsmokers. significant difference was found in fev1 (0.003*), fvc (p value 0.002*), fev1/fvc (0.001*). fev1/fvc ratio of < 0.70 was noted in 89.5% and 18.5% of total passive smokers and nonsmokers respectively (obstructive air way pattern). 55% of subjects with reduced lung function parameters also reported chronic cough and shortness of breath. conclusion: airway obstruction was found among majority of passive smokers, confirmed by reduced lung function test. key words: environmental tobacco smoke, spirometry, lung function parameters, passive smokers. introduction it contains nicotine, ammonia, benzopyrine and carbon monoxide (co) which are extremely harmful for human 2,3 health. it is estimated that two times more co and nicotine and 15 times more formaldehyde are emitted from side stream smoke than main stream and these emission are appox. three times more toxic than the 2 mainstream element of ets. increase emission of co from burning tip of smoking devices impair the body's ability to efficiently diffuse and transport oxygen leading to tissue hypoxia, reduction in exercise tolerance and shortness of breath among the active smokers as well as 5 passive smokers. all these factors along with nicotinic induced vasoconstriction causes precipitation of 6,7 pulmonary and cardiovascular ailments. some of the respiratory diseases include asthma, emphysema and lung cancers are depending upon effective dose of ets 8,9 over a time. subjects with exposure to ets have same ill effects as light active smokers (who smoke 6 1 0 c i g a r e t t e s / d a y ) . p a k i s t a n h a s h i g h t o b a c c o consumption because of high smoking rate of appox: 10,11 36% in pakistani men and 69% in women. smoking is considered an undesirable practice among pakistani women due to cultural barriers in our society. pakistani women are considered to be minority in terms of active smoking but majority as passive smokers. evidences are 12 showing that half of the pakistani and chinese women jafmdc jan-june 2019;vol.1, no.1 dr. sadaf zia associate professor university medical and dental college faisalabad maj. gen.(r)prof.dr. hamid shafiq hi(m) professor aziz fatimah medical and dental college, faisalabad. dr. fauzia jamshed postgraduate/mcps trainee pns shifa hospital karachi dr.rana muhammad tahir salam,sonologist aziz fatimah medical and dental college, faisalabad. correspondence: dr. sadaf zia e.mail: drsadafzia9@gmail.com environmental tobacco smoke (ets) or passive smoking is an emerging burden on the society, affecting 1 the quality of individual's life. according to world health organization (who) ets is referred to the involuntary inhalation of burning tobacco products emitted from the cigars, pipe, bidi, cigarettes, wave (shisha) and other smoking devices by nonsmokers in 2 proximity of smokers. however the most common source is the cigarette, as tobacco is most widely used in 2 this form worldwide. passive smokers are not only exposed to tobacco exhaled by smokers (main stream smoke) but as well as from side stream smoke (smoke released from the end of a burning cigarette), which 2 contain about 4/5 of total smoke. more than 4000 compounds including carcinogens, are emitted from burning cigarettes and cigars etc. 3 environmental tobacco smoke and pulmonary functions inclusion criteria all self-reported volunteers with history of exposure to passive tobacco smoking through cigarette, bidi and cigar were included as the passive smokers. subjects who had no significant exposure to tobacco smoking were taken as nonsmokers. all the included participants were not previously screened for copd and had no previous history of any treatment for airway obstruction exclusion criteria active smokers, exposures to factory smoke, male passive smokers, subjects who were unable to perform procedure due to oral lesions or with spine and thoracic cage deformities (kyphosis, scoliosis and fused ribs,) were excluded. subjects who had previous diagnosis of respiratory diseases including, asthma/copd, restrictive lung disease, tuberculosis and lung cancers. subjects with history of systemic diseases affecting the respiratory system were also excluded. individuals with existing or previous therapies for airway obstruction such as bronchodilators and steroids and with morbid obesity 2 with bmi ≥40 kg/m were excluded. (in order to avoid confounders and limit bias). proper history taking and clinical examination of all the subjects were done as per specially designed structured proforma. more stress was laid on the personal history (addictions), residential area, occupational history, family history etc. to find the source of passive smoking. question concerning symptom related to copd such as cough with sputim and breathlessness were also inquired. confidentiality and anonymity of the each participant was assured. after taking informed consent and explaining the procedure, each participant was subjected to spirometry test, using calibrated compact spirometer. forced expiratory st volume in 1 second (fev1), force vital capacity (fvc) and fev1/fvc ratio were determined according to guidelines by european respiratory society (ers) and 19 american thoracic society (ats). after correcting volume and zeroing spirometry pod, spirometry were performed by seating subject in upright position and using a nose clip to avoid air leakage through nose. volunteers were asked to take tidal breathing for 1 minute followed by inhaling as deeply as possible and then exhaling as deeply as possible through a noncompressible mouthpiece for at least 6 seconds (99% of the air bursts out forcefully in the first six seconds).three acceptable measures were taken to minimize the errors. highest reading was saved for data as per ats and ers 20 guidelines gold criteria was used to assess lung function test. fev1 80% was taken as normal, fev1 < 80% as stage 1, fev1 between 79-50% as stage ii and 30-40% as stage iii and ≤ 30% was taken as stage iv are frequently exposed to indoor ets and its exposure to pregnant women are the leading cause of preterm deliveries, low birth weight babies, sudden infant death 2, 3, syndrome, atopic asthma and ear infections in neonate. 13 hospitalization of 35.4% children with respiratory ailments including pneumonia and reduced lung function 14 are attributed to ets or second hand smoking. children are more vulnerable to respiratory problems due to smaller bronchial tree and less developed immune 15 system. ets is the constant threat to the health of females as wells children. it results in compromising the 15, 16 quality of life of future generation. studies conducted in past have reported that involuntary inhalation of cigarette smoke increases 2530 % risk of getting cardiovascular diseases and 20 -30% risk for lung cancer 17 among passive smokers. study conducted in china has documented that 1.9 million mortalities in chinese 18 population due to copd are attributed to ets. 6000 17 premature deaths globally are attributed to ets. ets is a preventable risk factor for human health. it is imperative to highlight this hazardous risk factor and launch effective awareness programs for the general population. such measures can prevent or decrease the load of diseases related to active as well as passive smoking. safety of women and children who constitute the major part of population across the world need to be looked after. females have an important role in the family in taking care of their spouse and children along with other family members. in developing countries, like ours, females are mostly neglected resulting delay in the diagnosis /management of their ailments. lack of knowledge among the smokers frequently results in spreading of environmental tobacco smoke among family members friends and colleagues .this has direct 15 impact on their physical as well mental health. smokers should know their responsibilities and quit smoking to save themselves as well as their family members/peoples around them. this study was specially designed to evaluate lung function tests of the female passive smokers (who are frequently exposed to ets) as compared to nonsmoker females of their age with similar socioeconomic background. methodology the current cross sectional study comprised of 250 female subjects, age ranging from 1545 years. the study was conducted from september 2018 to november 2018 in a private hospital of faisalabad. subjects participated voluntarily. ethical approval from the ethical committee was taken prior to commencement of the study. volunteer subjects were female employees, visitors, or attendants of hospitalized patients. sadaf zia et al. 4jafmdc jan-june 2019;vol.1, no.1 environmental tobacco smoke and pulmonary functions 21 copd. fev1/fvc < 70% were considered as copd fev1/fvc is reported as a decimal fraction. it helps to minimize the miscommunication as recommended by 3,19 american thoracic society. statistical analysis data was analyzed by using spss 20 version. data is expressed as mean and standard deviation for continuous variables (age height weight bmi, lung function parameters).categorical variables are presented as 2 frequency (n) and percentage (%) .x test was used to compare percentages. independent ttest was applied to compare the means of spirometric parameters (fev1, fvc, fev1/fvc) between study groups. p value ≤ 0.05 was taken as significant. results this study comprised of 250 subjects including passive smokers and nonsmokers. the basic characteristics of all subjects are presented in table-1. figure 1 is indicating distribution of study population. it reveals that 153(61.2 %) of total study population was exposed to ets. table 2 is showing that out of total 250 subjects, 155 (62%) were found to have air way obstruction. it further indicates that 89.5% and 18.5% of total passive smokers and nonsmokers respectively had undiagnosed airflow obstruction determined by fev1/fvc ratio of < 0.70. difference was statistically significant with p value 0.0001* (table2). 55% of subjects with reduced lung function parameters were also reported chronic cough and shortness of breath but they never screened for copd prior to this study. mean fev1, fvc and fev1/fvc ratio were lower in passive smokers as compared to non-smokers. all three spirometric parameters were lower in passive smokers as compared to nonsmokers but greater reduction was noted in fev1 (p values 0.003*) and fev1/fvc (p value 0.001*) values as compared to fvc (p value 0.002*) (figure 2). sadaf zia et al. table 1: descriptive of study population study variables mean std. deviation age(years) 22.57 3.94 height(cm) 156.50 6.11 weight( g) 57.4 11.50 bmi (kg/m 2) 23.70 3.12 fev1(l/s) 3.15 1.16 fvc(l/s) 3.55 0.63 fev1/fvc 1.89 0.31 bmi: body mass index, cm: centimeters, kg: kilograms, m: meters l/s liters/seconds, fev1: force expiratory volume in 1 st second, fvc: force vital capacity discussion majority of pakistani population comprises of females and children, who are more vulnerable to morbidities and 22 injuries associated with environments. these innocent lives are continuously suffering from the environmental 5 table 2: air flow obstruction among the study population determined by fev1/fvc ratio of < 0.70 study subjects air flow obstruction fev1/fvc ratio of < 0.70 yes n (%) no n ( %) total passive smokers 137( 89.5) 16(10.5) 153 nonsmokers 18( 18.5) 79(81.5) 97 total 155(62) 95( 38) 250 p value 0.0001* p value is obtained by x 2 test. = 0.05 is considered as significant. fev1/fvc ratio of < 0.70 is gold criteria for diagnosis of copd st fev1: force expiratory volume in 1 second, fvc: force vital capacity comparison of mean by ttest p value ≤ 0.05 is considered as significant figure1: distribution of passive smokers and non smokers among study population. (n= 250) jafmdc jan-june 2019;vol.1, no.1 figure 2: comparison of lung function test among study population.(n= 250) environmental tobacco smoke and pulmonary functions 1 undiagnosed copd. although we found reduction in all three studied parameters but greater decline was found in fev1 and fev1/fvc in contrast to fvc. these results are also supported by many other researches conducted in pakistan as well as other regions across the world in the 20, 25,26 ,27 past. health promotion and prevention is the most neglected part of our society. health awareness and motivational programs should be arranged by public and private health professionals concerning this issue. smokers should be motivated to cease smoking and lessen the ets for provision of safer environment for our nation building blocks and to save innocent lives. conclusion majority of the studied population had exposure to tobacco smoke (ets). undiagnosed air way obstruction was found in passive smokers. fev1,fvc, and fev1/fvc ratio, are lower in passive smokers than nonsmokers, which is indicative of deterioration of lung function. this study proved beyond doubt that passive smoking has negative effect on lung functions. strength and limitation the strength of the study was its standardized protocol like the questionnaire and gold standard test spirometry for assessment of lung functions. this study would be more scientific if we could have the opportunity of c l i n i c a l a s s e s s m e n t s o f s y m p t o m s a n d p o s t bronchodilator spirometry for the subjects with lower lung function parameters. (diagnostic criteria for copd by gold). due to a cross-sectional nature of the study, we cannot infer the association between passive smoking and decline in lung functions, further studies with longitudinal nature are needed. the study population was recruited from only one hospital which may not represent whole female population of pakistan. recommendation implementation for assuring legislation to ban smoking at public places and transports to provide 100% smoke free environment from government side ,as recommended by who framework convention on tobacco control (fctc). conflict of interest: none funding source: none pollution for which they are not responsible. according to global adult tobacco survey (gats) 2014, 86% of the pakistani population has exposure to ets. 4550% exposure is indoor at homes, 76-86% is in a restaurant 12 and on public transportation. major part of the pollution is attributed to environmental tobacco smoke spreading from the male smoker population which has impact on physical as well as mental health of the peoples around 15 them. females and children whose family members are smokers, are at risk of getting pulmonary as well as extra pulmonary morbidities. it is estimated by the previous researches that the children of smokers have higher rates of respiratory problems like asthma, pneumonia and lower and upper respiratory tract infections, lung cancers and frequent hospitalization than 23 children of nonsmokers. many studies in the past were conducted to highlight the health issues of the children but relatively very few documentation on female passive smokers who have the major contribution in taking care of their families are available. female are mostly ignored in our society and less importance is given to their health. it was found that half of the pregnant women who are exposed to indoor involuntary smoking, results not only in the reduction of their lung functions but also of their babies, thus compromising the quality of lives of future 24 generation too. very few studies were performed in the past to evaluate the lung function of females. aim of this study was to evaluate the lung functions of healthy female passive smokers by spirometry and compare it to nonsmoker females of the same age group and social background. 61.2% of the total current study population was exposed to ets, this figure corroborates the results documented by zubair t who reported 63.84% of same 1 exposure in his studied population at karachi. bird y, etal study also reported 50% of exposure to ets in 25 their studied mexican population. our study found significant reduction in fev1, fvc and fev1/fvc in female passive smokers as compared to the nonsmoker females. current study found that the 62% of the total studied population had undiagnosed airway obstruction with lung function parameters less than 70%. 89.5% and 18.6% of total passive smokers and nonsmokers respectively have air way obstruction with a statistically significant difference ( p value 0.0001*). 55% of subjects with reduced lung function also reported presence of symptoms like cough and breathlessness .this study is in agreement with the study conducted by zubair t and his colleagues at one of the renowned public sector hospital at karachi who reported decline in lung function parameters in passive smokers and 12.24% of exposed population had sadaf zia et al. 6jafmdc jan-june 2019;vol.1, no.1 environmental tobacco smoke and pulmonary functions 10.mal r, rizvi n, rathi s. prevalence of smokers among air-conditioned coaches, pakistan. j pak med assoc. 2001; 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[last accessed on 2016 aug 22]. india. journal of pharmacy & bioallied sciences. 2017; 9(1):44. 20. bruce h. culver, brian l. graham, allan l. coates, jack wanger etal recommendations for a standardized pulmonary function report an official american thoracic society technical statement. am j respir crit care med. 2017; 196(11): 1463–1472. 21. jawed s, ejaz s, rehman r. influence of smoking on lung functions in young adults. j pak med assoc. 2012;62(8):772–775. 22. global initiative for chronic obstructive lung disease. pocket guide to copd diagnosis management and prevention. amazon: global initiative for chronic obstructive lung disease; 2016. 23. qureshi fm, khalid n, nigah-e-mumtaz s, assad t, noreen k. first aid facilities in the school settings: are schools able to manage adequately?. pakistan journal of medical sciences. 2018; 34(2):272-76. 24. hammad m, atta k, manzoor m, tariq m, saeed z, masood z, et al.association of passive smoking with respiratory symptoms and clinical correlates, among married women, in a rural community in islamabad. j pak med assoc. 2010; 60:601-4. sadaf zia et al. author`s contribution dr. sadaf zia: study design, data collection, manuscript writing, revised and approved the manuscript. maj. gen. (r) prof. dr. hamid shafiq hi(m): study design, supervise throughout the research, manuscript writing, revised all the intellectual and scientific contents and approved the manuscript. dr. fauzia jamshed: study design, data analysis, result interpretation, write up of manuscript, editing and formulation of tables, revised and approved the manuscript. dr. rana muhammad tahir salam: data collection, manuscript writing, revised and approved the manuscript. 8jafmdc jan-june 2019;vol.1, no.1 page 1 page 2 page 3 page 4 page 5 page 6 journal.cdr original article chronic obstructive pulmonary disease (copd) screening is still a challenge in pakistan anam rehman, hamid shafiq, shireen jawed, fakiha behram abstract background:chronic obstructive lung disease (copd) is a highly preventable disease with smoking as most recognizable risk factor globally. copd remains undiagnosed worldwide due to unavailability of gold standard spirometry. technical difficulties in this procedure, faced by patient result in over and under diagnosis of this prevalent disease. objective of this study was to screen the undiagnosed air way obstruction which reflects the copd among the smokers and nonsmokers. pefr was used for assessment, as it is simple, reliable and easily available way at most of the health care centers. methodology:a cross sectional study was conducted from may 2018 to dec 2018 at private medical institute and private hospital in faisalabad. it comprised of 200 males (smokers and nonsmokers) who had no previous history of diagnosis of copd. relevant information related to smoking including pack years and medical history specially related to copd was inquired on structured questionnaire. air way obstruction was assessed by pefr using vitalograph compact. data was analyzed by spss 21 version. continuous variables are presented as mean and standard deviation (sd) and compared by independent t-test among study groups. categorical variables are expressed 2 as proportions and compared by x test. p value ≤ 0.05 was considered significant. results: results are showing that 91.56% of the studied smokers have air way obstruction based on yellow and red zones of pefr. out of total copd smokers 62.7% were in yellow zone and 28.9% were in red zone. only 29.1% of nonsmokers have pefr values within yellow. none of nonsmoker was in red zone (p value 0.001*). pefr was significantly lower in smokers in comparison to nonsmokers (p value 0.003*). 95.5% of subjects in red zone were symptomatic, while only 51.2% of subjects in yellow zone were symptomatic considering mild to severe air flow obstruction. conclusion:smokers and nonsmokers have undiagnosed airway obstruction with symptoms reflecting copd but greater proportion of smoker were involved. pefr was lower in smokers as compared to nonsmokers. key words: air way obstruction, undiagnosed copd, smokers, nonsmokers, pefr, spirometry introduction 1 2020. existing prevalence data related to copd varies universally due to different surveys techniques, 1 diagnostic criteria and approaches. burden of this disease is continuously increasing at alarming rate because of continued exposure to its risk factor specially 1 smoking. due to increasing prevalence of smoking in developing countries, burden of copd is expected to rise by next 30 years and by 2030 death rates are expected to be increased by 4.5 million due to copd and related 1 conditions. the countries where tobacco consumption is higher are at risk of increasing burden of this disease. early stages of the copd can be asymptomatic which can be prevented to progress by smoking cessation, increasing physical activity, and early detection and 5,4 treatment. lower estimates of prevalence worldwide are based on self-reporting of a physician's diagnosed copd, only a small proportion have documented 1.2 spirometry findings across the world. this reflects the 1 u n d e r o r o v e r d i a g n o s i s o f c o p d . i t r e m a i n s undiagnosed in many subjects with persistent airflow limitation particularly in developing countries with poor 2,6 resources. undiagnosed individuals may be susceptible to exacerbation-like pneumonia, pneumothorax, and premature mortalities due to missed opportunities for jafmdc jan-june 2019;vol.1, no.1 dr. anam rehman senior demonstrator aziz fatimah medical and dental college, faisalabad. maj.gen. (r) prof. dr. hamid shafiq hi(m) professor aziz fatimah medical and dental college, faisalabad. dr. shireen jawed, associate professor aziz fatimah medical and dental college, faisalabad. fakiha behram final year student (bs biotech) foreman christian college lhr (fc college) correspondence: dr. shireen jawed email: drshireenjawed@gmail.com chronic obstructive pulmonary disease (copd) is a progressive pulmonary disorder associated with poor quality of life and one of the leading cause of mortality 1 worldwide. it is a global public health crisis with smoking being recognized as its most important 2,3 causative factor. it is characterized by persistent respiratory symptoms and air flow limitation due to air way or alveolar abnormalities caused by exposure to 1 toxic chemicals or gases. global prevalence of copd 1,4 is 11. 7% with 3 million death annually. it is currently th 4 leading cause of mortality across the globe which is rd expected to be 3 leading cause of death by the year 18 copd in pakistan assessment by the primary health care professionals due to lack of feasibilities including spirometry may results in 12 high prevalence of this public health crisis. initiatives for early detection and treatment of copd and cessation of cigarette smoking prevent the loss of lung functions and produce public health benefits. primary health care professionals may play significant role in early and accurate diagnosis of copd by screening all the patients in high risk group like chronic smokers by using pefr as alternative to spirometry during their primary care visits. global initiative for chronic obstructive lung disease (gold) encourages new researches worldwide in this highly prevalent disease to develop innovative approaches for early screening of undiagnosed copd and planning its management and prevention to reduce its 1 burden on population. according to gold report revised in 2018, no data is available showing the e ff e c t i v e n e s s o f s p i r o m e t r y i n t h e d i a g n o s i s , management and improving copd outcomes in the 1 individuals without developing significant symptoms. gold criteria recommend spirometry for only s y m p t o m a t i c s u b j e c t s b u t n o t f o r s c r e e n i n g asymptomatic subjects. keeping this in mind this study was designed to screen undiagnosed air way obstruction which reflects copd patients among smokers and nonsmokers using pefr as a diagnostic tool.this procedure is simple, reliable and easily available, therefore it is proposed as a surrogate of spirometry for diagnosis of copd. objectives to investigate the undiagnosed air way obstruction which reflect the copd among smokers and nonsmokers subjects using pefr as a diagnostic tool. to compare pefr among smokers and nonsmokers. methodology this cross sectional study was conducted at private medical college and hospital in faisalabad from may 2018 to dec 2018. it comprised of 200 male subjects of 20 to 40 years age. after taking ethical approval from the ethical committee of institute and hospital, participants were selected from the employees of above mention centers by non-probability convenience sampling technique. initially 250 subjects were approached and relevant information about ethnicity, occupation, and lifestyle, history of smoking including duration and pack years (number of cigarettes per day by years), history of persistent dyspnea, cough, sputum, chest pain, allergies and frequent respiratory infections, systemic and respiratory diseases were recorded on structured proforma. drug history specially related to air way obstruction like bronchodilators and steroids was prevention, modification of risk factors and observation 6 of lung function decline particularly among the smokers. previous epidemiological studies reported that 75% of 5,7 copd patients remain undiagnosed due to scarcity of clinical suspicion and under use of spirometry as it is not 8,9 widely available. gold standard test for diagnosis of copd is spirometry but technical difficulties in performing this procedure and unavailability of spirometer and trained technicians frequently limit usage, especially at basic health units (bhu); providing 7,10 primary health care level universally. although this procedure is a non-invasive and safe and reproducible but its use is not feasible at many clinical setups. in the private setups this procedure is expensive and an unaffordable test for many patients in resource-poor 8,9 countries. forced expiratory volume in 1 second (fev1) and force vital capacity (fvc) are spirometric parameter used for assessment of lung function and diagnosis of symptomatic copd. early stages of copd can be asymptomatic and frequently be misdiagnosed 9 until it is clinically apparent and advanced, therefore 1 spirometry is not recommended for these individuals. spirometric measurements are not always valid because most of the patients have difficulties in expiring fully in 7,10 order to provide fvc and remain undiagnosed. according to global initiative for chronic obstructive lung disease (gold) report that fev1 is unreliable marker to assess the severity of breathlessness, exercise 1 limitation and health status impairment. in this context, pefr measurement is widely available alternate to 8 spirometry. it is expiratory parameter obtained by peek flow meter or compact vitalograph. it is a simple index of pulmonary functions which measures the caliber of the airways and commonly used in researches and clinical 11 practices. the main advantages of pefr are simplicity 10 and reliability of its procedure. it is a valuable tool in lung functions studies for diagnosis, assessment of severity of airway obstruction and selection of the 10,11 treatment regimes. various clinicians can develop copd management plans including admissions and discharges of patients based on green-yellow-red zones of pefr classification as per guidelines by american lung association due to availability of peak flow meter in 11 clinical setting. it is highly sensitive and accurate index of airway obstruction. air way obstruction in smokers is 12 symptomless in earlier stages, but can be easily picked 13 by pefr. pefr may not be able to accurately identify gold stage, but previous studies reported usefulness of peak flow rate measurements in copd screening 9,10 following subsequent confirmatory spirometry. under reporting of the symptoms by the patients and poor anam rehman et al. 19jafmdc jan-june 2019;vol.1, no.1 copd in pakistan percentages. proportions of subjects with green–yellowred zone of pefr classification for air way obstruction 2 were reported. chi square test (x ) was used to compare the proportions of copd among smokers and nonsmoker. percentages of symptoms were also 2 compared by x test. p ≤ 0.05 was taken as statistically significant. results study population comprised of 200 male subjects with mean age 21± 4.72. basic characteristics of study population are presented in table 1. table 2 is showing the frequencies and percentages of copd among smokers and nonsmokers based on pefr classification (greenyellow and red zone). results reveal that 91.56% of the studied smokers had air way obstruction based on yellow and red zones of pefr. out of total copd smokers 62.7% of the smokers were in yellow zone and 28.9% were in red zone considering mild to severe air flow obstruction. in contrast to smokers, only 29.1% of nonsmokers had pefr values in yellow zone, being in early stages of air flow obstruction. none of the 2 nonsmoker was in red zone. x test shows significant difference among both groups (p value 0.001*) (table 2). subjects in yellow zone (alert zone) and red zone (emergency zone) reported cough with sputum, breathlessness, wheeze and chest tightness but they did not take any medication for airway obstruction nor they were screened for copd before enrollment in study. (self-reported) (table 3). 95.5% of subjects in red zone were symptomatic, while only 51.2 % of subjects in yellow zone, showing early stages of air flow obstruction, were symptomatic. rest were asymptomatic. based on pefr zones and presence of symptoms, current study found that 108 (54%) of total population including smokers and nonsmokers have undiagnosed copd. taken. questions related to assessment of breathlessness and cough were also emphasized as these are two main symptoms along with air flow limitation recommended 1 for diagnosis of copd (according to gold criteria). selfreported undiagnosed male cigarette smokers of age 2040years (who reported smoking more than 100 cigarettes 12 in their life regularly and had no history of previous diagnosis of copd and treatment for airway obstruction) and nonsmokers (who never smoke or smoke less than 100 cigarettes in their life and don't have previous history of copd or treatment for airway obstruction) of the same age were included in the study. female smokers to prevent the gender bias, subjects with cigar, shisha and other types of smoking, subjects who were unable to perform procedure and with thoracicspine deformities (kyphosis, scoliosis and fused ribs) were excluded. subjects who had previous diagnosis of respiratory diseases including, asthma/copd, restrictive lung disease, tuberculosis and lung cancers and with history of systemic diseases affecting the respiratory system, subject on existing or previous therapies like bronchodilators and steroids for airway obstruction were also excluded from this study. after taking informed consent the anthropometric measurements including height in centimeters and weight in kg were obtained by stadiometer. bmi was calculated by weight in kg/height 2 in m and preliminary clinical examination was done to exclude any systemic disorder affecting respiratory system. pefr was recorded by calibrated vitalograph compact following standard guidelines by american thoracic society (ats). the subjects were instructed to take deep breath and exhale with forced expiration as hard as possible in a single blow into the apparatus while maintaining an air tight seal between lip and mouth piece. to avoid contamination disposable mouthpiece was used for each subject. test manoeuvre for each patient was repeated three times and highest reading was considered for analysis. pefr readings were classified into three zones as per american lung association. pefr of 80 to 100% was considered as green zone (safe zone), while between 50 to 80% was classified as yellow zone (alert 11 zone) and < 50% was red zone (zone of emergency). statistical analysis statistical analysis was conducted on spss 21 version. descriptive data including age, height, weight, bmi and pefr is described as mean ± standard deviation (sd). mean values for pefr among smokers and nonsmokers was compared by independent t-test. undiagnosed copd was analyzed as a dichotomous outcome (absence versus presence) and presented as frequencies and anam rehman et al. 20jafmdc jan-june 2019;vol.1, no.1 anthropometric measurements mean ± sd age (age) 21.89± 4.72 height (cm) 158.38 ±13.09 weight(kg) 62.04 ± 12.60 bmi (kg/m2) 24.62± 3.42 pefr (l/s) 5.88± 1.03 table 1: descriptive of studied subjects (n=200) bmi= body mass index, pefr ( peak expiratory flow rate) sd= standard. deviation, cm= centimeters, m=meters kg (kilogram), l /s (liters/ seconds) (table 3) figure1 is showing the comparison of mean pefr by independent t-test. it is indicating that pefr is significantly lower in smokers in contrast to nonsmokers (p value 0.003*). regression analysis is showing the significant positive association of pefr with height copd in pakistan copd in developing countries adversely affecting the 14 lung functions. most of the copd patients remain undiagnosed worldwide due to unavailability of gold standard procedure, spirometry in routine clinical 8,15 practices specially at primary health care centers. it is expensive and unaffordable for many middle and lower class patients. most of the patients fail to perform this procedure accurately, resulting in under or over diagnosis of copd. previous researches reported that only small proportion of physician-diagnosed copd patients have 12 documented spirometry findings available globally. due to lack of structured copd screening program, and uncommon use of spirometry for the evaluation of patients with chronic respiratory symptoms, the prevalence of undiagnosed air way obstruction is anticipated to be high, especially among chronic 12 smokers who are high-risk population for this ailment. in comparison to this pefr measurements are easy and widely available. it is an important mean to assess the lung functions and airway obstruction and has pivotal role in diagnosis and prognosis of obstructive and 16 hyperactive pulmonary diseases. it can be easily used in screening the population at risk of copd as it is inexpensive and affordable. in contrast to spirometry, it is a simple procedure and patient can easily perform it. early screening of obstructive disease with pefr and cessation of cigarette smoking can prevent its damaging 16 effects on respiratory system. current study found significant reduction in pefr in smokers than nonsmokers (5.17 vs 6.85). this finding was consistent with sawant gv et al, mukherjee s and various other studies who also documented decline in pulmonary function and 16,17 pefr inflammation is the hallmark of cigarette smoking. hyper-secretion of inflammatory mediators results in hyper-reactivity and increase in tone of alveolar 16 smooth muscles. broncho-pulmonary leakage and edema further contribute to alveolar walls thickness and airway narrowing affecting both small and large 17,19 airways. collectively all these factors promote airway obstruction limiting air flow, decrease diffusing capacity 18 and subsequent decline in pefr. quitting smoking can 8 reverse these harmful consequences. however, persistent tobacco smoking can progresses to permanent destruction of alveolar walls and deforming broncho11 pulmonary passage worsening the ventilatory function. some previous studies also documented reduced diffusing capacity in smokers most probably due to a lower pulmonary capillary blood flow in smokers in 13 contrast to non-smokers. all these changes are the possible explanation of limited ventilatory functions among smokers. current study found that 91.5 % of the smokers have undiagnosed airway obstruction based on pefr. by classifying the severity of air way obstruction using zones guided by american lung association, out of total copd smokers 62.7% have pefr values within 7050% and lie in yellow zone (zone of alert) having mild to moderate airway obstruction. 28.9% copd smokers are in red zone (emergency zone) with pefr values < 50% (β = 0.005, p value 0.030*).pefr is not significantly associated with age (p value=0.12), bmi (p value 0.41) and weight (p value 0.34) (table 3) table 2: frequencies and percentages of copd among the study population based on pefr values (n= 200) anam rehman et al. 21jafmdc jan-june 2019;vol.1, no.1 study groups subject without copd n (%) subjects with copd n (%) total ( 200) green zone pefr ( 10080%) yellow zone pefr (80-50%) red zone pefr ( < 50%) total smokers 7 (8.4) 52 (62.7) 24 (28.9) 76 (91.56) 83 non smokers 83 (70.9) 34 (29.1) 00 34 (29.1) 117 p value 0.001* 2 percentages are compared by x test, statistically significant at p value < 0.05 table 3: pulmonary symptoms based on pefr zones (n=108) symptoms subjects with copd n= 108 yellow zone (n=86) pefr (80 -50%) red zone(n=22) pefr ( < 50%) n(%) n(%) productive cough 11(12.8) 17(70.8) dry cough 6(6.97) 8 (36.3) breathlessness 30(34.9) 15(62.5) wheeze 3(3.5) 10(45.5) chest tightness 18(20.9) 13(59.5) symptomatic 44(51.2) 21(95.5) asymptomatic 42(48.8) 1(4.5) p value 0.004* symptoms are self-reported by study participants 2 x test was used to check difference in percentages statistically significant at p value < 0.05. figure1: comparison of pefr among study groups (n= 200) pefr = peak expiratory flow rate, comparison by t-test statistically significant at p value < 0.05 discussion current study was conducted to highlight the chronic pulmonary obstructive disease (copd) which is highly preventable but manageable disease. air flow limitation is the hallmark of this disease which results from 1 continuous exposure to noxious particles or gases. cigarette smoking is the most common risk factor for copd in pakistan 3. laniado-laborín r. smoking and chronic obstructive pulmonary disease (copd). parallel epidemics of the 21st century. int j environ res public health. 2009 ;6(1):209-24. 4. rabe kf, etal chronic obstructive pulmonary disease. lancet.2017;389 (100082):1931-1940. 5. çolak y, afzal s, nordestgaard bg, vestbo j, lange p p r o g n o s i s o f a s y m p t o m a t i c a n d s y m p t o m a t i c , undiagnosed copd in the general population in denmark: a prospective cohort study. lancet respir med. 2017 ;5(5):426-434. 6. martinez ch mannino dm jaimes fa etal. undiagnosed obstructive lung disease in the united states. associated factors and long-term mortality. ann am thorac soc. 2015; 12: 1788-1795. 7. almagro p, soriano jb. underdiagnosis in copd: a battle worth fighting. the lancet respiratory medicine. 2017;5(5):367368. 8. pothirat c, chaiwong w, phetsuk n, liwsrisakun c, bumroongkit c, deesomchok a, theerakittikul t, limsukon a. peak expiratory flow rate as a surrogate for forced expiratory volume in 1 second in copd severity classification in thailandint j chron obstruct pulmon dis. 2015;10: 1213-1218. 9. fir perez-padilla r, vollmer wm, vzquez-garcia jc, et al. can a normal peak expiratory flow exclude severe chronic obstructive pulmonary disease? int j tuberc lung dis. 2009;13(3):387-393. 10. mahboub b, alzaabi a, soriano jb, et al. casefinding of chronic obstructive pulmonary disease with questionnaire, peak flow measurements and spirometry: a cross-sectional study. bmc res notes. 2014 ; 7:241. doi: 10.1186/1756-0500-7-241. 11. nighute s, buge k, kumar s. effect of cigarette smoking on peak expiratory flow rate: a short review. int. j. curr. res. physiol. pharmacol. 2017; 1(1):3-5. showing severe copd.in contrast to smokers only 29.1% of nonsmokers have pefr values within yellow zone indicating early stages of copd. none of them is in red zone.subjects in yellow and red zone were considered as undiagnosed copd because they also report on and off cough, sputum and breathlessness but they don't take any medication for air way obstruction. similar findings were also presented by sawant gv, who reported lower pefr readings in 84% of smokers as 16 compared to 60% among nonsmokers. these findings suggest that cigarette smoking is the key factor to influence airway obstruction in smokers and limit 20 ventilatory function. this study also found that 95.5% of subjects in red zone are symptomatic, while only 51.2% of subjects in yellow zone are symptomatic and rest are asymptomatic, indicating early stages of airway obstruction can be asymptomatic. these findings are supported by cohort study conducted in denmark which reported asymptomatic cases of undiagnosed copd in 5 general population. this study adds pertinent information about copd which is a common hazard of tobacco smoking. early diagnosis of copd may motivate smokers for quitting smoking, which is the only measure to improve future prospects of chronic smokers. conclusion pefr was lower in smokers as compared to nonsmokers. smokers and nonsmokers have undiagnosed airway obstruction with symptoms reflecting copd but greater proportions of smokers were involved showing mild to severe condition. pefr can be used as a simple tool to screen population being at high risk. limitation and recommendations i. pefr screening of high risk population such as smokers should be done in order to diagnose copd at early stages with an emphasis for cessation of smoking. ii. health awareness programs should be increased to motivate people to quit smoking in order to prevent morbidity and mortality associated with it. funding source: � � nil conflicts of interest: � � nil� reference 1. global initiative for chronic obstructive lung disease (gold). global strategy for the diagnosis, management, and prevention of chronic obstructive lung diseases (gold). 2018report. https://goldcopd.org/wpcontent/uploads/2017/11/gold-2018-v6.0-finalrevised-20-nov_wms.pdf 2. labonté le ,tan wc ,li pz,et al. undiagnosed chronic obstructive pulmonary disease contributes to the burden of health care use. data from the can cold study. am j respir crit care med. 2016; 194: 285-298 anam rehman et al. 22jafmdc jan-june 2019;vol.1, no.1 copd in pakistan 12.fu sn, yu wc, wong ck, lam mc.prevalence ofundiagnosedairflow obstruction among people with a history of smoking in a primary care setting. int j chron obstruct pulmon dis. 2016 ;11:2391-2399. e collection 2016. 13. mridha maa , amin mr , kabir arml, peak expiratory flow rate (pefr)-a simple ventilatory lung function test j shaheedsuhrawardy med coll, 2011;3(2): 44-47. 14. medabala t, rao bn, glad mohesh mi, kumar p. effect of cigarette and cigar smoking on peak expiratory flow rate. journal of clinical and diagnostic research: jcdr. 2013;7(9):1886. 15. stafyla e, kotsiou os, deskata k, gourgoulianis ki missed diagnosis and over treatment of copd among smoking primary care population in central greece:old problems persist. int j chron obstruct pulmon dis.2018;5:13:487-498. 16. sawant gv, kubde sr, kokiwar pr. effect of smoking on pefr: a comparative study among smokers and non smokers in an urban slum community of hyderabad, india. international journal of community medicine and public health. 2017;3(1):246-50. 17. mukherjee s, banerjee g, mahapatra abs. peak expiratory flow rate changes with relevant variables in a population of eastern india. indian j physiol pharmacol 2018; 62(3) : 372–379. 18. kaur h, singh j, makkar m, singh k, garg r. variations in the peak expiratory flow rate with various factors in a population of healthy women of the malwa region of punjab, india. journal of clinical and diagnostic research: jcdr. 2013; 7(6):1000. 19. bajentri al, veeranna n, dixit pd, kulkarni sb. effect of 2-5 years of tobacco smoking on ventilatory function tests. j indian med assoc. 2003; 101(2):96108. 20. medabala t, rao bn, mohesh gm, praveenkumar mp. the effect of ageing on vital capacity and peak expiratory flow rate in healthy non-smoking agricultural workers. int j med health sci. 2012;1(4):47-52. anam rehman et al. 23jafmdc jan-june 2019;vol.1, no.1 author`s contribution dr. anam rehman: study design, data collection, interpretation of results, manuscript writing maj. gen. (r) prof. dr. hamid shafiq hi (m): study design, supervise all the research work reviewed and approved the manuscript. dr. shireen jawed: acquisition of data, statistical analysis, interpretation of results, formulation of tables, writing the manuscript. reviewed and approved the manuscript page 16 page 17 page 18 page 19 page 20 page 21 j aziz fatm med den college july december 2020; vol. 2, no. 2 53 original article frequency of plantar fasciitis among females in teaching profession riaz hashmi, laiba naeem, sana arif, umme habiba, rabia irfan mir, maham zafar abstract objective: to find the frequency of plantar fasciitis among females teachers in sialkot and to explore the relationship of heel pain due to plantar fasciitis with age, body mass index (bmi), type of shoes wearing and standing hours. methodology: this cross-sectional study was the project of sialkot college of physiotherapy (scpt). it was conducted in february to march 2018 after taking ethical approval from institutional review board of scpt (irbscpt dpt-115-2018). sample size was 150 subjects. female teachers of age ranged 25-60years ,who fulfill inclusion criteria were enrolled by convenience sampling technique from the sialkot based colleges. data was collected by administering plantar fasciitis pain/disability scale (pfps) questionnaire among the female teachers. data was analyzed by spss22. results: this study was comprised of 150 participants with mean age30.69±5.44years. mean of height, weight and bmi were 1.63± 0.34, 60.17±11.71, 23.68±4.39 respectively. mean±sd of visual analogue scale (vas) and total pfps scores were 5.78±2.461 and 36.5±13.5 respectively. of total population 46.3% of subjects have plantar fasciitis. middle sole of foot was the most affected area by plantar fasciitis (pf), followed by ball of foot, heel and toe with subsequent values52(34.7%),43(28.7%),37(24.7%) and 18(12%) respectively the significant difference in mean vas score for pain intensity was found among the subjects with and without pf (p value 0.000*). plantar fasciitis was frequently found in subjects with higher age group than younger ones (p value 0.000*). current results showed that 31% of total subjects with pf were used to wear flat shoes, whereas only 16 percent wear heel shoes and 23% were using both type of shoes (heel& flat). however this association was not found to be significant on regression analysis. current results of regression analysis also did not find any significant impact of bmi (p value 0.50) and standing hours (p value 0.804) and types of shoes (p value 0.620) on the development of plantar fasciitis. plantar fasciitis was positively associated with age (p value 0.002). conclusion: plantar fasciitis is found among teachers, commonly affecting middle sole area of the foot. pf is positively associated with age; however standing hours and bmi was not associated with it. keywords: plantar fasciitis, shoe type, foot wear, teachers, standing hour introduction plantar fasciitis (pf) is one of the most common cause riaz hashmi, bspt, ms physiotherapist syed medical complex, sialkot laiba naeem, dpt demonstrator sialkot college of physical therapy, amin welfare & teaching hospital, sialkot sana arif, dpt 3d lifestyle, sialkot umme habiba, dpt physiotherapist tahiri foundation, sialkot rabia irfan mir, dpt sialkot college of physical therapy maham zafar, dpt sialkot college of physical therapy correspondence: riaz hashmi, email: riazhashmiphysio@gmail.com of the heel pain.1 it is appreciated as a thickened fibrous aponeurosis that originates from the medial calcaneal tuberosity and inserted into heads of the metatarsal bones. it holds the medial arch and give tensile strength to metatarsals specially when these bones are subjected to crucial bending forces propulsion or when foot absorbs forces in the stance phase of gait.2 inflammation and degenerative changes of plantar fascia due to the repetitive stress and trauma specially on its origin at the medial calcaneal tuberosity of the heel and peri-fascial structures causes pf and subsequent central to medial plantar heel pain. in different studies 11 to 15 % of adult symptomatic foot pain is due to plantar fasciitis.3although it is selflimiting condition, but pain may become chronic and disabling requiring the rehabilitation of patient for several months. it might influences quality of life of patients and limit their physical activity.1external j aziz fatm med den college july december 2020; vol. 2, no. 2 54 factors like prolong standing, prolong sitting, walking barefoot, and prolonged weight bearing are intensifying risk factors for this condition.3 intrinsic factors like obesity, foot deformities including pes cavus associated with high medial arch during weight bearing involving intrinsic muscle weakness and pes planus (flat foot) associated with lower or flat medial arch due to which foot pronated excessively and comes directly in contact with the floor and subjected to increase tensile load within the plantar fascia and thereby increasing the risk of the micro-injuries and inflammation.2,5 contradictory findings by previous studies have been reported about predisposition of pf among gender, some studies have reported equal predominance of pf in both gender while other showed male or female predominance.2,6evidences are available showing the impact of occupation solely affecting plantar region, causing pf. occupation involving prolong standing, sitting, running or long walking triggers the pain caused by this conditions.7 people doing job comprising of long standing hours like teaching have high incidence of developing heel pain due to plantar fasciitis.2,7it can also develop due to footwear which doesn’t fit properly in feet and can put direct stress at the plantar fascia and this have impact on the mobility.2 impairment of the windlass mechanism of foot also causes plantar fasciitis resulting heel pain.7 due to the muscular weakness in plantar fasciitis, the fascia of the ipsilateral side of the affected limb becomes thickened and causes stiffness of the foot resulted in greater load beneath the forefoot during gait and disturbs the gait pattern.8 one of the significant occupation teaching is also associated with this condition but still it is not well studied. evidences are available showing high prevalence of the musculoskeletal pain among school teachers. teachers taking long teaching sessions often suffer from heel, leg and lower back pains. the prevalence of heel pain is high in the old age teachers might be because of reduced elasticity of the plantar fascia and delayed healing process with advancing age.9 prolonged standing and using the black board causes tightness of hamstring muscle. its tightness can lead to the changes in gait mechanics and windlass mechanism of the foot. increase in the forefoot pressure causes tensile overload and traction injury of plantar fascia attached on the calcaneus bone causing persistent heel pain.10 hamstring tightness can also limit the posterior ankle motion that can be compensated by the excessive pronation of the subtalar joints and subsequent increase in tension on the plantar fascia.10 evidences are available showing that the heel pain is also intensified by gaining the weight. excess body weight changes the normal gait mechanics and more weight is shifted to the lower extremities causes’ mechanical loading of the foot and plantar fasciitis.10 adopting the precautionary measures like reduction in body weight, using comfortable shoes for long teaching sessions and proper standing mechanics for long hours and change in positions after particular gap might cause improvement.9,11 many numerous previous researches conducted in pakistan mainly focused on musculoskeletal disorders including back, shoulder and neck pain among teachers while neglecting foot pain associated with plantar fasciitis which severely limit the physical activities. the aim of this study was to explore frequency of plantar fasciitis among the female teachers. we also aimed to assess the impact of possible internal aggravating factors like age, obesity, standing hours and types of shoe wearing on this condition. methodology it was a crosssectional study conducted during february to march 2018. this study was project of sialkot college of physiotherapy. ethical approval was granted by institutional review board of mentioned institute (irb-scpt-dpt-115-2018). female teachers of age ranged 25-60 years were enrolled from sialkot based colleges by convenient sampling technique. sample size was calculated using 150 sample size at 5% margin of error and 95% confidence interval. house-wives, females belonging to other professions, newly employed teachers (less than 6 months) and male teachers were also excluded. teachers with previous history of heel surgery, neuronal disorders, achilles tendinopathy, diabetes mellitus and peripheral vascular disease were also excluded. all relevant information including age, height, weight, bmi and questions related medical history were recorded in predesigned proforma. plantar fasciitis pain or disability scale (pfps) questionnaire was administered among the female teachers. the pfps questionnaire includes series of questions related to pain and control questions for pf.12 unilateral plantar heel pain, more severe when person walks after awaking in morning or prolonged sitting are the characteristic features for pf.6 pfps also includes visual analogue scale (vas) to assess intensity of pain. the vas scores pain was rating the pain on a scale of 1 to 100 points. cut off points of vas scores for intensity of the pain has been recommended as: no pain (0–4 mm), mild pain (5-44 mm), moderate pain (45–74 mm), and severe pain (75–100 mm).13 pfps score more than 35 points considered heel pain due to pf.12 questions to measure the effect of pain on routine riaz hashmi et al j aziz fatm med den college july december 2020; vol. 2, no. 2 55 physical activities were also included in pfps.12 data was entered on spss22 for analysis. numerical data was expressed as mean with standard deviation. mean age and vas scores among subjects with and without pf were compared by independent t-test. frequency and percentages were used to describe categorical data. regression analysis was used to assess associations of pfps scores with age, standing hours, types of shoes and bmi. p-value ≤ 0.05 was considered to be the statistically significant. results this study was comprised of 150 participants of mean age 30.69±5.44years. the descriptive statistics of studied population is shown in table1. mean ± sd of vas and total pfps scores were 5.78±2.461 and table 1: descriptive of the studied population (n=150) descriptive parameter mean sd age (years) 30.69 5.44 height (m) 1.63 0.34 weight (kg) 60.17 11.71 body mass index (bmi) kg/m2 23.68 4.39 vas 5.78 2.64 pfps 36.5 13.5 sd: standard deviation, vas: visual analogue scale, pfps: plantar fasciitis pain/disability scale 36.5±13.5 respectively (table1). of total population 46.3% subjects have plantar fasciitis (table 2). middle sole of foot was the most affected area by pf, followed by ball of foot, heel and toe with subsequent table 2: comparison of age & vas score among subjects with & without plantar fasciitis (n=150) plantar fasciitis frequency n (%) age mean ±sd vas score mean ± sd yes 70(46.7) 30.36± 4.15 7.45±2.01 no 80(53.3) 27.58±4.21 4.3±2.2 p value 0.000* 0.000* p-value ≤ 0.05 is taken significant, vas: visual analogue scale values 52(34.7%), 43(28.7%), 37(24.7%) and 18(12%) respectively. the significant difference in mean vas score was found among the subject with and without pf (p-value 0.000). pf was frequently found in subjects with higher age group than younger age with p-value 0.000 (table 2). these results were justified by regression analysis which indicates positive association between age and total score for plantar fasciitis (p-value 0.002) (table 3). our result showed that pf was commonly found in subjects using flat shoes as compared to subjects using heels. our results showed that 31% total subjects with table 3: regression analysis between aggravating factors and plantar fasciitis (n=150) independent variable beta coefficient (β) standard error pvalue age 0.0743 0.234 0.002* standing hours -0.01 0.05 0.80 bmi -0.17 0.25 0.50 shoe type -0.61 1.24 0.62 dependent variable is plantar fasciitis score, p value ≤ 0.05 is taken significant pf were used to wear flat shoes, whereas only 16 % wear heel shoes and 23% were using both type of shoes (heel and flat). however this association was not found to be significant on regression analysis (p value 0.62). current results of regression analysis also did not find any significant impact of bmi (p value 0.50) and standing hours (p value 0.80) on the development of plantar fasciitis (table 3).physical activities affected by pf are shown in table 4. table 4: physical activities affected by pain caused by plantar fasciitis activity 0 = not at all 1 = very little 2 = moderate 3 = severe walking in morning 35(23.3%) 89(59.3%) 23(15.3%) 3(2%) standing on toes 54(36%) 58(38.7%) 33(22%) 5(3.3%) driving 53(35.3%) 41(27.3%) 49(32.7%) 7(4.7%) climbing stairs 8(5.3%) 40(27.7%) 82(54.7%) 20(13.3%) bending over 16(10.7%) 35(23.3%) 59(39.3%) 40(26.7%) walking bare foot 48(32%) 12(8%) 50(33.3%) 40(26.7%) standing after watching movie 49(32.7%) 75(50%) 23(15.3%) 3(2%) running for short distance 9(6%) 24(16%) 65(43.3%) 52(34.7%) discussion teaching profession makes lasting impact in building nations due to its fundamental role in development of students into future productive generation. teachers’ diligent work for long hours involves standing continuously on a daily basis. they are indulged in performing their activities efficiently, not even plantar fasciitis among teacher j aziz fatm med den college july december 2020; vol. 2, no. 2 56 realizing the negative impact of those on their physical health particularly affecting musculoskeletal system. during the course of their assigned task, such as frequent reading, preparing lessons and marking of assignments involves head down posture. moreover, prolong standing and writing on a blackboard during teaching sessions lead to muscle fatigue and overuse of joints, thence prone to musculoskeletal diseases.14 despite having important role of teachers for capacity building of our future generation ,teaching profession has not been given sufficient attention in the literature concerning their physical and mental health. numerous researches have been done concerning back pain and knee and ankle pain. as compared to these area of interest, limited data is available concerning the prevalence of plantar fasciitis which is commonly associated with long working hours, prolong standing, prolong sitting and writing on black boards in the teaching profession.6,14 in the current study, 46.7% of studied population was suffering from plantar fasciitis. contrary to our findings higher percentages of plantar fasciitis was reported by recent study by alqahtani et al that reported prevalence of 85.5% foot pain among the teacher.9 in our studied population the most frequent affected area was mid sole region of the foot. in contradiction of our results, study conducted at saudi arabia, found heel was the region of the foot being most frequently affected. however, our results concerning second common site and least common areas being affected was ball of foot and fore foot area respectively. these finding are also in accordance with aforementioned study.9in present study, plantar fasciitis was most commonly found in middle age group than the younger ones. these results are confirmed by the regression analysis that showed significant positive association between the age and the development of pf. our results are justified by the study conducted in saudi arabia by goweda et al, documenting 1.72 times higher risk of plantar fasciitis with increasing age and it is most frequently found in middle age group of 40-60 years.15 these findings are discordant with alqahtani et al that reported higher percentages of plantar fasciitis among teachers of older age group with high load of teaching sessions.9 previous studies have reported increased risk of plantar fasciitis with increasing bmi and showed positive association between these.15,16contrary to this; current results did not reveal any significant association between bmi and pf. beta coefficient of this shows negative association of occurrence of pf and standing hours. however this association was not found to be significant. but our these results are justified by the previous studies reporting a prolonged sitting as a risk factor for pf.17 inconsistent results were reported by goweda et al reported positive impact of long standing hours and use of tight and improper shoes. our results are in contrast with the results of rosenbaum et al reported that high prevalence of pf among the subjects performing the long standing hour’s duty.18 our result shows that pf was commonly found in subjects using flat wears as compared to subjects using heel foot wear. this finding is aligned with the fact described by thompson et al who stated that high heels with slight elevation are responsible for offloading the weight at plantar fascia origin on the calcaneus thence reducing the foot pain. this study reported low prevalence of pf among the subject using high heel foot wears.19 goweda et al reported that that use of tight and improper shoes predisposes to pf.18 plantar heel pain is a common disabling symptom among the teachers. they should avoid prolonged sitting and standing during their duty hours. teacher being the treasure of one’s nation must deserve health authorities’ attention in order to avoid suspecting the disabilities concerning the postural discomforts. hence, health educational sessions should be arranged by the authorities concerning their postural comfort in order to avoid the development of the plantar fasciitis and other musculoskeletal disorders. limitations: this is cross sectional study so casual relation is not established. results were not generalized to whole population because of small sample size comprising only female participants. it should be generalized to both genders. conclusion plantar fasciitis is found among teachers, commonly affecting middle sole area of the foot. pf is positively associated with age; however standing hours and bmi was not associated with it. recommendations: future researches on broader scale are recommended to support this study with thorough assessment. funding source: none. conflicts of interest: none. references 1. ling y, wang effects of platelet-rich plasma in the treatment of plantar fasciitis: a meta-analysis of randomized controlled trials. s.medicine (baltimore). 2018 ;97(37):e12110. doi: 10.1097/md.0000000000012110. riaz 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centers of makkah, kingdom of saudi arabia. jhiph.2015;45(2):71-75. 16. yin mc, ye j, yao m, cui xj, xia y, shen qx, et al."is extracorporeal shock wave therapy clinical efficacy for relief of chronic, recalcitrant plantar fasciitis? a systematic review and meta-analysis of randomized placebo or active-treatment control led trials." arch phys med rehabil. 2014;95(8):1585-1593. 17. miller le, latt dl. chronic plantar fasciitis is mediated by local hemodynamics: implications for emerging therapies. nam j med sci. 2015;7(1):1–5.doi: 10.4103/1947-2714.150080 18. rosenbaum aj, dipreta ja, misener d. “plantar heel pain".med clin north am. 2014;98(2):339–352. doi: 10.1016/j .mcna.2013. 10.009 19. thomas mj, menz hb, mallen cd.plantar heel pain. bmj. 2016;353:i2175. doi: 10.1136/bmj.i2175. itis and health-care use. j am podiatr med assoc. 2018;108 (6): 442-448. doi: 10.7547/15-169. received: 11 aug 2020, revised received: 13 sep 2020, accepted: 23 sep 2020 author’s contribution: riaz hashmi laiba naeem sana arif study design, acquisition of data and manuscript writing. revised and approved the articles. data acquisition, manuscript writing, reviewed and approved the manuscript. study design, data analysis and interpretation and write up of results. revising manuscript critically for important intellectual content. umme habiba study design, data collection, contributed to review the article and approved it. rabia irfan mir study design, data collection, drafting and formatting of final manuscript. revised and approve the final manuscript. maham zafar data collection, revised manuscript and approved it. all authors are responsible for the integrity of the data and the accuracy of the data analysis. plantar fasciitis among teacher https://pubmed.ncbi.nlm.nih.gov/28717618/ https://pubmed.ncbi.nlm.nih.gov/28717618/ https://pubmed.ncbi.nlm.nih.gov/26081472/ https://pubmed.ncbi.nlm.nih.gov/26081472/ https://pubmed.ncbi.nlm.nih.gov/31548445/ 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https://www.ncbi.nlm.nih.gov/pmc/articles/pmc4325390/ https://dx.doi.org/10.4103%2f1947-2714.150080 j aziz fatm med den college july december 2020; vol. 2, no. 2 58 original article efficacy of herbal preparation(cystone) in management of urinary stone disease nauman khalid, muhammad sohail , muhammad tahir bashir malik, hanan noor, muhammad saifullah, muhammad akram malik abstract objective:to evaluate the efficacy of herbal medicine cystone, in reduction of renal and ureteric stone size. methodology: this observational follow up study was conducted in urology department, madinah teaching hospital, associated with university medical and dental college, faisalabad after obtaining the ethical approval from the mentioned institute during march 2018 to december 2018. one hundred and ninety two patients coming to urology outpatient clinic, fulfilling the inclusion criteria were recruited in the study. out of which 27(14.06%) were lost in follow up and were excluded from study. out of remaining 165 patients, 99 were male and 66 female patients. all patients with renal stones who were freshly prescribed with oral tablet cystone twice a day for four weeks were enrolled in the study and were followed for stone size with ultrasonography followed for the duration of four weeks patients were followed till the primary endpoint. results: one hundred and seven (64.84%) patients cleared the stone, 10 (6.06%) patients had their stone size reduced,17(10.3%) patients had their stone size unchanged and 31 (18.78%) patients had their stone size increased. no significant adverse effects were noted during the study that required the patients to stop the treatment. there was significant decrease in stone size from initial mean stone size1.57 ±0.08 mm to end point stone size 0.69 ±0.09 mm after treatment with cystone (pvalue 0.000). conclusion: the mean stone size was reduced after using this herbal preparation for one month. keywords: renal stone, ureteric stone, cystone. introduction urinary stone disease and its recurrence rates have been rising at an alarming rate globally. it is a common challenging health problem affecting all ages, genders and races throughout the world with an incidence of 12%.1 it is one of the most prevalent urologic diseases in south asia with prevalence of 5%–19.1%.2 this growing trend is because of lifestyle modifications including lack of physical activity, poor dietary habits ____________________________________________________________ dr. nauman khalid, mbbs,fcps assistant professor university medical and dental college fsd dr. muhammad sohail, mbbs,fcps associate professor university medical and dental college fsd dr. m.tahir bashir malik, mbbs,fcps assistant professor medicine fmu fsd dr hanan noor, mbbs.fcps senior registrar faisalabad medical university fsd dr muhammad saifullah, mbbs,fcps senior registrar faisalabad medical university fsd dr. muhammad akram malik, mbbs,fcps professor university medical and dental college fsd correspondence: dr. nauman khalid email: drnaumankhalid@hotmail.com and global warming due to the industrialization and modernization in the societies.1 formation of urinary stones is a complex and multifactorial process. it depends on intrinsic factors such as age, gender, heredity factors and extrinsic factors like climate, geography, dietary, mineral composition, and water intake contributes in calculogenesis.1 majority of the urinary stones are composed of oxalates, calcium salts and phosphates crystal. renal stones are the consequence of nucleation of crystals, causing their rapid growth and aggregation that can interact with some intrarenal structure of urinary tract leading to the accumulation within the kidney and renal collecting tubular system leading to further aggregation and secondary nucleation to form the clinical stone. saturation and super saturation of urine with respect to stone chemical constituents favors nucleation and the growth of crystals, hence further facilitate stone formation. however some studies have reported the presence of inhibitors of crystal formation in the urine that suppresses calculogenesis in normal healthy individual.3 stone recurrence remains to be a serious health problem globally and measures for its prevention is debatable and required to understand its logistic mechanics.1 previous studies have reported strong association of renal stones with metabolic j aziz fatm med den college july december 2020; vol. 2, no. 2 59 syndrome including diabetes mellitus, hypertension or adiposity.2 it was estimated that 2 to 3% of the endstage renal cases are attributed to the urolitihiasis.1 urolithiasis is treated by the various methods, which may range from the conservative approach, dissolution therapy, minimally invasive procedures like extracorporeal shockwave lithotripsy and invasive techniques like percutaneous nephrolithotomy or open surgery. despite new mode of treatments have been introduced in decades, current treatments under practice have customary issue related to the poor patient compliance, cost effectiveness of the treatment and adverse effect profile. therefore, an effective, pocket friendly, safe treatment owing the good patient compliance is highly desirable which could also play pivotal role in prevention for stone growth. as intervention for the urinary stone disease has significant burden on the society, resources and health system, hence, cost effective oral therapy is easiest.4 cystone, which is an oral herbal formulation used for treating urolithiasis in various parts of the world, is being studied since 1954 in indian subcontinent as well as middle east. each tablet contains extracts of saxifraga ligulata, cyperus scariosus, powder of purified shilajeet and hajrul yahood bhasma, achyranthes aspera, onosma bracteatum, and vernonia cinerea and didymocarpus pedicellata.5 these herbal constituents have various effects on urine composition. numerous previous studies have shown its beneficial effects on renal stones, although some showed conflicting data.3 hence, this study was aimed to observe patients with urolithiasis, already taking treatment with cystone to evaluate its efficacy in decreasing the renal and ureteric stone size. methodology this observational follow up study was conducted in urology department of madinah teaching hospital from march 2018 to december 2018. ethical approval was taken from university medical and dental college, the university of faisalabad with the vide no. tuf/dean/2018/32.patients with age ranging 15-75 years, presenting with renal and ureteric stones in which immediate surgical intervention was not absolutely indicated or the patients were not willing for active surgical intervention or other extracorporeal shockwave lithotripsy and were recently prescribed tablet cystone for treating renal stones were eligible to participate in study. the patients who were taking cystone tablet twice daily were enrolled in this observational follow up study after consenting their data to be used for research purpose.6 benefits and risks were clearly explained to participants and anonymity was assured. all patients underwent routine diagnostic tests of urinary stones including ultrasound, x-ray, computed tomography urography (ctu), intravenous urography (ivu) and renal profile. stone size and location were recorded. the patients requiring immediate intervention, deranged renal functions, obstructing renal stones, patients having food or drug allergy, pregnant ladies and patients who lost in follow up were excluded from the study. the study’s primary endpoint was stone size after four weeks of regular use of medication. secondary end point was development of stone or drug related complications like obstructive uropathy, fever, pyuria, vomiting, haematuria or severe pain with vomiting, itching, rash, drug allergy and overall compliance to the treatment. patients were followed weekly for assessment for duration of four weeks. during follow up patients were evaluated for colicky pain at loin, abdominal pain, hematuria, dysuria, nausea/vomiting, pain on micturition, tenderness in the lumber regions, fever/chills, and loss of appetite in addition to the evaluation of stone size. repeat ultrasonography were performed at endpoint for estimation of stones size in centimeters(in longitudinal axis).subjects with the absence of stones were enquired about expulsion of stones through urine passage. findings of these patients were also confirmed on computed tomography. statistical analysis: was performed by spss 22. continuous variables were expressed as mean and standard deviations. categorical variables were shown in frequencies and percentages. mean was compared by paired sample t test. p value ≤ 0.05 was considered significant. results a total of 192 patients were recruited in the study. twenty seven patients were lost in the follow up. remaining 165 patients out of whom there were 99(60%) male and 66(40%) were female. study participants were followed weekly for the duration of table1: paired sample t test showing change in renal stone size ( n= 165) initial stone size(cm) end point stone size (cm) mean difference (cm) 95% confidence interval of the difference p value mean ±sd mean ±sd mean ±sd 1.57±0.08 0.69 ± 0.09 0.87± 1.06 0 .711-1.038 0.000* endpoint refers to the analysed parameter change from baseline at 4 weeks, cm= centimetres p value ≤ 0.05 was considered significant. nauman khalid et al j aziz fatm med den college july december 2020; vol. 2, no. 2 60 four weeks for repeated assessments. mean age of presentation was 37.94± 13.42 years. mean ±sd of the initial renal stone size was 1.57±0.08 and endpoint stone sizes was 0.69±0.09 cm. mean difference in initial and end point stone size was 0.87±1.06cm, difference was statistically significant (pvalue 0.000). over all mean stone size was reduced. at end point in 107(64.84%) of patients, stones were not seen on renal scan, of these patients more than half (60%) were confirmed removal of stone through urine, while rest were unaware of removal. 10(6.06%) patients had their stone size reduced, 17(10.303%) patients had their stone size unchanged and 31(18.78%) patients had their stone size increased. discussion urinary calculi form as a result of physicochemical or genetic derangements leading to super-saturation of the urine with stone forming salts or less commonly from recurrent urinary tract infection with urease producing bacteria.7 although not fatal in most of the patients, urolithiasis is a main cause of morbidity resulting in hospitalization, leading to the days off from work.8 if conservative approach or invasive therapy is not preferred by the patient, they usually turn to medical therapy. although some oral medications may provide relief from pain, they may be ineffective in some patients. oral citrate is most commonly used medical treatment for preventing urinary stone disease.9 however, all the patients do not tolerate this drug and may still form stones while taking the treatment.10 owing to the cumbersome side effects of the oral medications, alternative herbal treatments have been used as therapy for thousands of years, especially in eastern civilizations.9 plants with medicinal qualities have been used for various illnesses since the beginning of humanity. cystone is a herbal treatment, developed for management of urinary stone disease. it was developed in 1943 and since then being used for the treatment of urolithiasis and uti. the literature evidences showed pharmacological properties of the ingredients of cystone including antimicrobial, antiinflammatory and antioxidant properties.11, 12 it also acts as an antispasmodic agent having diuretic and lithotropicproperties.13,14 current study showed that significant reduction in size of the renal calculi at primary endpoint of fourth week of treatment with the cystone as compare to initial point of treatment. (0.69± 0.48 versus 1.57± 1.07) current results are in accordance with palaniyamma study that also reported significant decrease in size of renal calculi.7 however, 10(6.06%) patients had their stone size reduced using cystone, 17(10.303%) patients had their stone size unchanged while 31(18.78%) of the patients had their stone size increased. in 107 (64.84%) of subjects stones were not identified with the scanning, reflecting expulsion/dissolution of kidney stones, more than half of these patients were self-reported the removal of stone in passage of urine. in previous study by erickson et al , patients were followed for one year and stone volume was precisely measured pre and post cystone treatment with three dimensional ct scanning. erickson reported increased stone volume and burden in those patients, suggesting no overall beneficial effect of using cystone herbal preparation.14 these findings of erickson was against to our results. disparity between our results and erickson might be because of duration of follow up. in our study we just observe our patients on cystone for follow up period of only one month whereas in erickson study it was of long duration of one year,15 might be stone volume in his study was increased due to use of cystone drug for long duration by his study participants. while other previous studies have reported that cystone was safe and effective in the treatment of urinary stone disease, with significant relief in clinical symptoms, decrease in stone size, and increased in urinary volume.5,16 the efficacy of cystone forte can be attributed to synergistic activity of all these herbs present in the formulation in the treatment of urolithiasis.5 the meta-analysis of 50 clinical studies showed that cystone is helpful in the treatment of urolithiasis taking into account the symptomatic relief, clearance of stones, increased urinary volume, and reduction in the stone forming constituents in urine with minimal side effects.17 limitations: small sample size and short duration of the study is our limitation. it should be conducted on a broader scale for a long duration with control group following strict protocol to validate the results to be implemented on overall population. conclusion the mean stone size was reduced after using the herbal prepration for one month whereas spontaneous clearance of urinary stones was seen in more than half of the subjects. funding source: none. conflicts of interest: none. efficacy of cystone for urolithiasis j aziz fatm med den college july december 2020; vol. 2, no. 2 61 author’s contribution: dr. nauman khalid study design, acquisition of data and manuscript write up. reviewed and approved the manuscript. dr. muhammad sohail study design, manuscript writing, reviewed and approved the manuscript. dr. muhammad tahir bashir malik data collection, manuscript writing, compiling and analysis of data, interpretation of results, formulate tables. reviewed and approved the manuscript. dr. hanan noor study design, data analysis write up and interpretation of results. revising manuscript critically for important intellectual content dr. muhammad saifullah dr. muhammad akram malik data analysis, manuscript writing, revising manuscript critically for important intellectual content data collection, revised manuscript and approved it all authors are responsible for research work, data integrity and the accuracy references 1. alelign t, petros b kidney stone disease: an update on current concepts.advurol.2018:4;2018:3068365.doi:10.1155/2018/3068 365 2. yu liu, yuntian chen, banghua liao, deyi luo, kunjie wang, hong li,et al epidemiology of urolithiasis in asia. asian j urol. 2018 ;5(4): 205–214.doi: 10.1016/j.ajur.2018.08.007 3. alelign t,petros b kidney stone disease:an update on current concepts.advurol.2018:4;2018:3068365.doi:10.1155/2018/3068365. 4. yu liu, yuntian chen, banghua liao, deyi luo, kunjie wang, hong li,et al epidemiology of urolithiasis in asia. asian j urol. 2018 ;5(4): 205–214. doi: 10.1016/j.ajur.2018.08.007 5. jayaramaiah k, anturlikar s, viswanatha g, agadihiremath t, patki p, rafiq m. cystone, a well-known herbal formulation, inhibits struvite crystal growth formation in single diffusion gel growth technique.j exp integr med. 2013; 3(1):51-55. 6. saigal cs, joyce g, timilsina ar. direct and indirect costs of nephrolithiasis in an employed population: opportunity for disease management. kidney int. 2005;68(4):1808-14.. 7. palaniyamma d, jeyaraman r. evaluation of efficacy and safety of a herbal formulation cystone forte in the management of urolithiasis. j urol res, 2017; 4(4):1093. 8. ross js. randomized clinical trials and observational studies are more often alike than unlike. jama intern med. 2014;174(10):1557.doi:10.1001/jamainternmed.2014.3366. 9. erickson sb, vrtiska t, canzanello v, lieske j. cystone® for 1 year did not change urinechemistry or decrease stone burden in cystine stone formers. urological research.2011;39(3):197-203. 10. raja a, wood f, joshi hb. the impact of urinary stone disease and their treatment on patients’ quality of life: a qualitative study. urolithiasis.2020; 48:227–234. 11. gurocak s, kupeli b. consumption of historical and current phytotherapeutic agents for urolithiasis: a critical review. j urol. 2006;176, 450-455 12. mattle d, hess b. preventive treatment of nephrolithiasis with alkali citrate: acritical review. urol res.2005;33(2):73-79. 13. prasad k , chandra d. antioxidant activity, phytochemical and nutrients of didymocarpus pedicellata r.br from pithoragarh, uttarakhand himalayas, india. j of pharmacol& clin res 2017:4(3);1-8. 14. hasan s. pharmacological and medicinal use of achyranthes aspera. int j science & environment & technology. 2014: 3 (1): 123-129. 15. erickson sb, vrtiska tj, lieske jc. effect of cystone® on urinary composition and stone formation over a one year period. phytomed.2011;18(10):863-867. doi:10.1016/j.phymed.2011.01.018. 16. kumaran mgs, patki ps. evaluation of an ayurvedic formulation (cystone), in urolithiasis: a double blind, placebo controlled study. eur j integr med. 2011;3:23–28 17. karamakar d, patki p. evaluation of efficacy and safety of a herbal formulation cystone in the management of urolithiasis: meta-analysis of 50 clinical studies. the internet journal of alternative medicine.2008:8(1);1-10. nauman khalid et al received: 17 may 2020, revised received: 13 jul 2020, accepted: 20 sep 2020 https://pubmed.ncbi.nlm.nih.gov/29515627/ https://pubmed.ncbi.nlm.nih.gov/29515627/ https://www.ncbi.nlm.nih.gov/pubmed/?term=liu%20y%5bauthor%5d&cauthor=true&cauthor_uid=30364478 https://www.ncbi.nlm.nih.gov/pubmed/?term=chen%20y%5bauthor%5d&cauthor=true&cauthor_uid=30364478 https://www.ncbi.nlm.nih.gov/pubmed/?term=liao%20b%5bauthor%5d&cauthor=true&cauthor_uid=30364478 https://www.ncbi.nlm.nih.gov/pubmed/?term=luo%20d%5bauthor%5d&cauthor=true&cauthor_uid=30364478 https://www.ncbi.nlm.nih.gov/pubmed/?term=wang%20k%5bauthor%5d&cauthor=true&cauthor_uid=30364478 https://www.ncbi.nlm.nih.gov/pubmed/?term=wang%20k%5bauthor%5d&cauthor=true&cauthor_uid=30364478 https://www.ncbi.nlm.nih.gov/pubmed/?term=li%20h%5bauthor%5d&cauthor=true&cauthor_uid=30364478 https://www.ncbi.nlm.nih.gov/pmc/articles/pmc6197415/ https://www.ncbi.nlm.nih.gov/pmc/articles/pmc6197415/ https://dx.doi.org/10.1016%2fj.ajur.2018.08.007 https://pubmed.ncbi.nlm.nih.gov/29515627/ https://pubmed.ncbi.nlm.nih.gov/29515627/ https://www.ncbi.nlm.nih.gov/pubmed/?term=liu%20y%5bauthor%5d&cauthor=true&cauthor_uid=30364478 https://www.ncbi.nlm.nih.gov/pubmed/?term=chen%20y%5bauthor%5d&cauthor=true&cauthor_uid=30364478 https://www.ncbi.nlm.nih.gov/pubmed/?term=liao%20b%5bauthor%5d&cauthor=true&cauthor_uid=30364478 https://www.ncbi.nlm.nih.gov/pubmed/?term=luo%20d%5bauthor%5d&cauthor=true&cauthor_uid=30364478 https://www.ncbi.nlm.nih.gov/pubmed/?term=wang%20k%5bauthor%5d&cauthor=true&cauthor_uid=30364478 https://www.ncbi.nlm.nih.gov/pubmed/?term=wang%20k%5bauthor%5d&cauthor=true&cauthor_uid=30364478 https://www.ncbi.nlm.nih.gov/pubmed/?term=li%20h%5bauthor%5d&cauthor=true&cauthor_uid=30364478 https://www.ncbi.nlm.nih.gov/pmc/articles/pmc6197415/ https://www.ncbi.nlm.nih.gov/pmc/articles/pmc6197415/ https://dx.doi.org/10.1016%2fj.ajur.2018.08.007 http://r.br/ journal.cdr review article initial systemic treatment of advanced non-small cell lung cancer muhammad kamran siddique , ehsanur-rahman , muhammad saqib khan abstract the incidence of lung cancer is rising worldwide and cigarette smoking is recognized major risk factor for lung cancer. non-small cell lung cancer (nsclc) constitutes majority of all lung cancer cases. the prognosis for nsclc remains poor. the five-year survival rate for all nsclc stages combined is 23% and for stage iv nsclc alone is 6%. the systemic chemotherapy has proved to prolong survival in some patients with advanced nsclc. the targeted treatments have recently become available for minority of patients with nsclc due to identification of sensitizing mutations and improved understanding of downstream molecular pathways. the immune check point inhibitors have redefined treatment for majority of nsclc patients who lack “sensitizing mutations” for targeted agents. this review discusses current standard treatment for advanced nsclc in first line setting. key words:non-small cell lung cancer, immune check point inhibitors, immunotherapy, targeted therapy, chemotherapy. introduction the systemic treatment (targeted therapy, chemotherapy and immunotherapy) has demonstrated significant and remarkable improvement in overall survival and quality of life in patients who present with advanced disease upfront or following their initial definitive treatment. the surgical resection or definitive radiation therapy may be appropriate for patients with a solitary metastasis. the preferred initial therapy for advanced nsclc is influenced by presence or absence of a sensitizing mutation (egfr, alk, ros1), presence of pd-l1 (programmed death-ligand 1) expression, squamous versus non-squamous histology, extent of disease and any associated symptoms. nsclc with sensitizing mutation the better understanding of molecular biomarkers and downstream pathways that drive malignancy in nsclc has initiated the formulation of targeted agents. the analysis of tumor for egfr, alk, ros1 and braf is strongly recommended for all patients with advanced nsclc, especially ones with non-squamous histology. egfr mutation the presence of an egfr mutation is strong predictor of response to egfr tkis (tyrosine kinase inhibitors) in advanced nsclc. in united states, the incidence of egfr tyrosine kinase mutations in nsclc of adenocarcinoma histology is around 10-15 percent and is seen more often in nonsmokers. the egfr mutations can be identified in up to 50 percent of the patients in 2 asian populations. the egfr tkis (geftinib, erlotinib, afatinib and osimertinib) are approved as single agents in first line setting for treatment of patients with sensitizing mutation in egfr.the egfr tkis significantly prolong pfs (progression free survival) as compared to standard platinum-based chemotherapy in this subgroup 3-6 of patients with sensitizing egfr mutations. the jafmdc jan-june 2019;vol.1, no.1 muhammad kamran siddique medical oncology/hematology allen cancer center nanticoke health services, seaford, de, united states dr ehsanur-rahman consultant medical oncology department of medical oncology northampton general hospital united kingdom dr muhammad saqib khan head of division minar cancer hospital multan, pakistan correspondence: muhammad kamran siddique kamsid50@yahoo.com almost seventy percent of lung cancer patients present with advanced disease that is not curable. the nonsmall cell lung cancer (nsclc) accounts for eighty percent of lung cancers. the systemic chemotherapy has been mainstay of treatment for patients with nsclc. the systemic chemotherapy has shown to improve survival and quality of life in some patients 1 with advanced stage nsclc. the identification of biomarkers in small percentage of advanced nsclc tumors, most notably egfr (epidermal growth factor receptor) mutations, alk (anaplastic lymphoma kinase) gene rearrangement or ros1 gene rearrangement, has redefined treatment options for patients harboring such sensitizing mutations. however, most of nsclc patients lack these sensitizing mutations and immunotherapy has emerged as an essential part of treatment for such patients. the intent of treatment for advanced nsclc patients remains palliative. the goals of treatment include prolonging survival and maintaining quality of life for as long as possible, while keeping the side effects of treatment to minimum. 42 non-small cell lung cancer ceritinib (second generation tki) has demonstrated activity in ros1-rearranged nsclc. in a phase ii trial involving patients with advanced ros1-rearranged nsclc, the orr with crizotinib was 62 percent, duration of response was 21 months, median pfs was 9.3 months and median overall survival was 24 months. moreover, the pfs was 19.3 months for patients who had not received crizotinib previously. sixty percent of patients with brain metastases achieved some degree of 18 disease control. certinib has not been compared to crizotinib in ros1-rearranged patients. other mutations the less common sensitizing mutations including braf, ret, trk, met, and kras have been identified and specific inhibitors are available. such patients should be included in clinical trials, whenever possible. the braf mutations have been identified in 1-3 percent of patients with nsclc (mostly smokers). the dabrafenib and trametinib combination has been approved for patients with braf v600e mutant advanced nsclc, who have 19 progressed on chemotherapy. nsclc without sensitizing mutation immune check point inhibitors in patients without sensitizing egfr or alk mutations, the use of pembrolizumab (immune check point inhibitor) has emerged as the first-line drug for advanced nsclc irrespective of histologic subtype or intensity of pd-l1 expression on tumor cells. in patients with pd-l1 negative nsclc, pembrolizumab and doublet chemotherapy combination is superior to chemotherapy alone. in patients with pd-l1 positive nsclc (especially with pd-l1 expression more than 50 percent), better efficacy of pembrolizumab and chemotherapy combination over pembrolizumab alone remains undetermined [figure 1]. keynote-024 randomized trial demonstrated that anti-pd1 therapy (pembrolizumab) was superior to platinum-based combination chemotherapy in first-line setting for advanced nsclc with pd-l1 expression on at least 50% of tumor cells and without sensitizing egfr mutations or alk rearrangements (the 50% cutoff for pd-l1 expression was used based on data from the keynote-001 trial that had shown higher objective r e s p o n s e r a t e i n t h i s s u b g r o u p o f p a t i e n t s ) . pembrolizumab arm had significantly better progressionfree and overall survival as compared to standard chemotherapy arm, which involved pemetrexed maintenance therapy for non-squamous nsclc patients. pembrolizumab group had higher response rate, longer duration of response, and less treatment-related 2 0 , 2 1 s i d e e f f e c t s t h a n c h e m o t h e r a p y g r o u p . impact on os (overall survival) is less evident in the clinical trials since egfr tkis were frequently used in s e c o n d l i n e s e t t i n g f o l l o w i n g p r o g r e s s i o n o n chemotherapy. among the egfr tkis, osimertinib (third generation tki) has demonstrated improved pfs compared to erlotinib and gefitinib (first generation 7 tkis). osimertinib has not been compared to afatinib (second generation tki). the egfr tkis are used only as single agent as no survival advantage has been demonstrated when used combined with chemotherapy. the treatment with an egfr tki should be continued until disease worsening or emergence of significant side effects. alk gene rearrangement alk gene rearrangement is detected in 4-5 percent of nsclc of adenocarcinoma histology in united states, mostly in nonsmokers and younger patients. the a d v a n c e d n s c l c w i t h p o s i t i v e a l k g e n e rearrangement should be treated with alk tkis (tyrosine kinase inhibitors). alectinib is preferred firstline therapy in this subgroup of patients. alectinib has better systemic and intracranial efficacy than crizotinib 8,9 and has more favorable side effect profile. ceritinib is second generation alk inhibitor and is approved as first line drug for alk gene rearrangement positive advanced 10-13 nsclc. brigatinib, another next-generation alk inhibitor, has been approved for administration in patients with alk-positive advanced nsclc, who have 1 4 either worsened or are intolerant to crizotinib. brigatinib may offer better systemic and intracranial disease control with less toxicity than ceritinib but has not been yet approved in first line setting. the treatment with alk tki is generally continued until there is disease progression or development of significant toxicities. ros1 gene rearrangement the ros1 tyrosine kinase gene rearrangement is observed in 1-2 percent of nsclc, mostly in younger 15 patients, nonsmokers and adenocarcinoma histology. crizotinib has shown marked effectiveness in advanced nsclc with ros1 gene rearrangement in first and subsequent lines of treatment. in an international study crizotinib usage in patients with ros1-rearranged nsclc led to objective response rate (orr) of 72 percent, median duration of response of 17.6 16 months and median pfs of 19.2 months. more than 80 percent of patients in this study had received at least one prior chemotherapy regimen. in another phase ii trial of crizotinib in east asian patients with ros1-rearranged nsclc, the median pfs 17 was 15.9 months. muhammad kamran siddique al. 43jafmdc jan-june 2019;vol.1, no.1 non-small cell lung cancer tumor mutational burden has emerged as another biomarker for immune checkpoint inhibition, which appears to be non-overlapping with pd-l1 expression. in the phase iii checkmate 227 trial, the use of nivolumab (immune check point inhibitor) and ipilimumab (cytotoxic t-lymphocyte antigen 4 inhibitor) as first line treatment decreased the risk of disease progression or death by 42% as compared to chemotherapy among patients with all subtypes of nsclc with a high tumor 25 mutational burden. the contraindications for immune check point inhibitor include connective tissue disease, interstitial lung disease and rheumatologic disease. chemotherapy patients with advanced nsclc and eastern cooperative oncology group (ecog) performance status (ps) of 2 or better have shown improved survival and quality of life with use of platinum doublet chemotherapy regimen. no platinum-based doublet is superior to another for unselected patients. pemetrexed has been approved for first-line, second-line, and maintenance treatment of nonsquamous nsclc. a phase iii trial has shown that use of pemetrexed/cisplatin as first line therapy for patients with nonsquamous nsclc has improved overall survival as compared to gemcitabine/cisplatin 26 group. the maintenance pemetrexed has shown to have superior os as compared to placebo following initial chemotherapy with pemetrexed or taxane-based 27,28 regimens. in the united states, carboplatin doublets are preferred over cisplatin doublets due to less toxicities with former. antiangiogenesis the addition of the antivascular endothelial growth factor antibody bevacizumab to a platinum-based doublet results in improved response rate and pfs, and higher os compared with chemotherapy alone. however, this combination has not been directly compared with the addition of pembrolizumab to platinum-based chemotherapy regimen. the cross-trial comparisons suggest improved outcomes with pembrolizumab over bevacizumab when used in combination with platinum-based regimens. the triple-drug regimen of carboplatin, paclitaxel and bevacizumab (followed by bevacizumab maintenance) has been approved for non-squamous nsclc based on ecog 4599 study. the median overall survival (os) was 12.3 months in the bevacizumab and chemotherapy c o m b i n a t i o n g r o u p a n d 1 0 . 3 m o n t h s i n t h e chemotherapy-only group. the median progression free survival (pfs) in the two groups was 6.2 and 4.5 months, respectively. the clinically significant bleeding and treatment-related deaths were higher in the bevacizumab keynote-189 phase iii trial demonstrated better overall survival and progression free survival with pembrolizumab, cisplatin/carboplatin and pemetrexed combination versus placebo, cisplatin/carboplatin and pemetrexed in patients with non-squamous nsclc. median progression free survival was 8.8 months in the pembrolizumab-chemotherapy arm and 4.9 months in the placebo-chemotherapy arm. the estimated overall s u r v i v a l a t 1 2 m o n t h s w a s 6 9 p e r c e n t i n t h e pembrolizumab-chemotherapy arm as compared to 49 percent in the placebo-chemotherapy arm. although the s u r v i v a l b e n e fi t a s s o c i a t e d w i t h a d d i t i o n o f pembrolizumab was seen in all subgroups of pd-l1 tumor proportion scores but the greater benefit was observed in the subgroup with a pd-l1 tumor expression 22 of 50% or more. keynote-407 phase iii trial demonstrated that p e m b r o l i z u m a b i n c o m b i n a t i o n w i t h s t a n d a r d chemotherapy (carboplatin and either paclitaxel or nabpaclitaxel) is superior to chemotherapy alone in first line setting in patients with metastatic squamous nsclc. the median overall survival increased by 4.6 months (15.9 months vs. 11.3 months) and median progression free survival by 1.6 months (6.4 months vs. 4.8 months). pembrolizumab combination arm demonstrated superior response rate and duration of response. there was no difference in outcomes regardless of whether the patients received paclitaxel or nab-paclitaxel. the survival benefit in pembrolizumab combination group was 23 independent of intensity of pd-l1 tumor expression. pembrolizumab is the only pd-1 inhibitor, which has shown superior survival over chemotherapy both as single agent and in combination with chemotherapy for first line treatment of advanced nsclc, regardless of histology. the data from phase iii impower131 trial showed that pd-l1 inhibitor atezolizumab in combination with carboplatin and nab-paclitaxel decreases the risk of disease progression or death compared to carboplatin and nab-paclitaxel alone by 29% in first line treatment of patients with metastatic squamous nsclc. there has 24 been no improvement in overall survival thus far. single agent pembrolizumab can be used in upfront treatment of patients with advanced nsclc with pd-l1 expression score of more than 50% due to correlation between higher pd-l1 expression in tumors and greater benefit with pembrolizumab. the usefulness of pd-l1 expression is limited and unclear in patients receiving combination of pembrolizumab and chemotherapy, given that the chemo-immunotherapy is superior to chemotherapy alone across all categories of pd-l1 muhammad kamran siddique al. 44jafmdc jan-june 2019;vol.1, no.1 non-small cell lung cancer pembrolizumab, bevacizumab, or pemetrexed as part of their first line treatment. these agents may be continued, d e p e n d i n g u p o n t o l e r a n c e , a s m a i n t e n a n c e . pembrolizumab may continue as single agent or can be combined with pemetrexed. similarly, bevacizumab may continue with or without pemetrexed. conclusion in conclusion, for advanced nsclc patients (regardless of histology) without a sensitizing mutation and with pdl1 expression of at least 50 percent, single agent pembrolizumab is judicious choice. however, for patients with high tumor burden or rapidly progressive disease the combination of pembrolizumab with chemotherapy may also be offered. for patients with advanced non-squamous nsclc without a sensitizing mutation and with pd-l1 expression less than 50 percent, carboplatin and pemetrexed combined with pembrolizumab for four to six cycles followed by pemetrexed and pembrolizumab maintenance is considered a standard therapy. for patients with advanced squamous nsclc, without a sensitizing mutation and with pd-l1 expression less than 50 percent, carboplatin, and either paclitaxel or nabpaclitaxel combined with pembrolizumab for four to six cycles followed by pembrolizumab maintenance is now a standard treatment. figure 1. initial management of advanced nsclc without a sensitizing mutation 29 and chemotherapy combination arm. in a meta-analysis of four trials (2194 patients) bevacizumab addition to platinum-based doublets significantly increased both os and pfs compared with chemotherapy alone. the effect on os was significantly greater among patients with adenocarcinoma compared with other histology. the addition of bevacizumab did 30 increase the risk of grade 3 or higher toxicities. pronounce trial compared pemetrexed and carboplatin induction followed by pemetrexed maintenance versus paclitaxel, carboplatin and bevacizumab induction followed by bevacizumab maintenance in patients with advanced non-squamous nsclc. there was no significant difference in terms of overall survival or pfs between both arms. different 31 toxicities were noted in both arms. point break trial compared carboplatin, pemetrexed and bevacizumab induction followed by pemetrexed and bevacizumab maintenance versus carboplatin, paclitaxel and bevacizumab induction followed by bevacizumab maintenance in patients with advanced non-squamous nsclc. the overall survival did not improve with the carboplatin, pemetrexed and bevacizumab regimen compared with the carboplatin, paclitaxel and bevacizumab regimen, although progression free survival was significantly better with carboplatin, pemetrexed and bevacizumab. the both regimens were 32 well tolerated but had different toxicity profiles. antiangiogenesis and immunotherapy the addition of the checkpoint inhibitor atezolizumab to chemotherapy and bevacizumab has shown improved efficacy over chemotherapy and bevacizumab in nonsquamous nsclc, irrespective of pd-l1 expression. in impower-150 study among the patients without sensitizing egfr and alk mutations, the median progression free survival was significantly longer in the abcp (atezolizumab, bevacizumab, carboplatin, paclitaxel) group than in the bcp (bevacizumab, carboplatin, paclitaxel). similarly, median overall survival among the patients without sensitizing egfr and alk mutations was longer in the abcp arm than in 33 the bcp arm (19.2 months vs. 14.7 months; p=0.02). in t h i s t r i a l a b c p ( a t e z o l i z u m a b , b e v a c i z u m a b , carboplatin, paclitaxel) group was not compared to acp (atezolizumab, carboplatin, paclitaxel) group so it is unclear whether adding bevacizumab to chemoimmunotherapy improves outcome. maintenance the maintenance therapy is offered if there is no evidence of disease progression following 4-6 cycles of induction treatment. majority of patients will have received muhammad kamran siddique al. 45jafmdc jan-june 2019;vol.1, no.1 pd-l1 expression >50% of tumor cells <50% of tumor cells pembrolizumab bulky or rapidly progressive disease platinum doublet and pembrolizumab (choice of chemotherapy agent to combine with platinum depends on histology) squamous cell carcinoma 4-6 cycles of carboplatin, paclitaxel and pembrolizumab followed by pembrolizumab maintenance nonsquamous carcinoma 4-6 cycles of carboplatin, pemetrexed and pembrolizumab followed by pembrolizumab and pemetrexed maintenance yes no non-small cell lung cancer seto t, et al. alectinib versus crizotinib in patients with alk-positive non-small-cell lung cancer (j-alex): an open-label, randomised phase 3 trial. lancet 2017; 390:29-39. 9. peters s, camidge dr, shaw at, gadgeel s, ahn js, kim dw, et al. alectinib versus crizotinib in untreated alk-positive non-small-cell lung cancer. n engl j med 2017; 377:829-38. 10. soria jc, tan ds, chiari r, wu yl, paz-ares l, wolf j, et al. first-line ceritinib versus platinum-based chemotherapy in advanced alk-rearranged non-smallcell lung cancer (ascend-4): a randomised, open-label, phase 3 study. lancet 2017; 389:917-29. 11. scagliotti g, kim t, crino l, liu g, gridelli c, novello s, et al. ceritinib vs chemotherapy (ct) in patients (pts) with advanced anaplastic lymphoma kinase (alk)-rearranged (alk+) non-small cell lung cancer (nsclc) previously treated with ct and crizotinib (crz): results from the confirmatory phase 3 ascend5 study. esmo 2016; #lba42_pr. 12. de castro jr g, tan ds, crino l, wu yl, paz-ares l. pl03. 07: first-line ceritinib versus chemotherapy in patients with alk-rearranged (alk+) nsclc: a randomized, phase 3 study (ascend-4). j thorac oncol. 2016; 12:s7. 13. shaw at, kim tm, crinò l, gridelli c, kiura k, liu g, et al. ceritinib versus chemotherapy in patients with alk-rearranged non-small-cell lung cancer previously given chemotherapy and crizotinib (ascend-5): a randomised, controlled, open-label, phase 3 trial. lancet oncol 2017; 18:874-86. 14. camidge dr, kim hr, ahn mj, yang jc, han jy, lee js, et al. brigatinib versus crizotinib in alkpositive non-small-cell lung cancer. n engl j med 2018; 379:2027-39. 15. bergethon k, shaw at, ou sh, katayama r, lovly cm, mcdonald nt, et al. ros1 rearrangements define a unique molecular class of lung cancers. j clin oncol 2012; 30:863. 16. shaw at, ou sh, bang yj, camidge dr, solomon bj, salgia r, et al. crizotinib in ros1-rearranged nonsmall-cell lung cancer. n engl j med 2014; 371:1963-71. disclaimer: none conflict of interest: none. source of funding: none references 1. burdett s, stephens r, 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lung cancer (optimal, ctong-0802): a multicentre, open-label, randomised, phase 3 study. lancet oncol 2011; 12:735-42. 5. zhou c, wu yl, chen g, feng j, liu xq, wang c, et al. final overall survival results from a randomised, phase iii study of erlotinib versus chemotherapy as firstline treatment of egfr mutation-positive advanced nonsmall-cell lung cancer (optimal, ctong-0802). ann oncol 2015; 26:1877-83. 6. sequist lv, yang jc, yamamoto n, o'byrne k, hirsh v, mok t, et al. phase iii study of afatinib or cisplatin plus p e m e t r e x e d i n p a t i e n t s w i t h m e t a s t a t i c l u n g adenocarcinoma with egfr mutations. j clin oncol 2013; 31:3327-34. 7. soria jc, ohe y, vansteenkiste j, reungwetwattana t, chewaskulyong b, lee kh, et al. osimertinib in untreated egfr-mutated advanced non-small-cell lung cancer. n engl j med 2018; 378:113-25. 8. hida t, nokihara h, kondo m, kim yh, azuma k, muhammad kamran siddiqueal. 46jafmdc jan-june 2019;vol.1, no.1 non-small cell lung 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cell lung cancer patients treated with bevacizumab in combination with carboplatin and paclitaxel: analysis of eastern cooperative oncology group trial 4599. j clin oncol 2008; 26:60-5. 30. soria jc, mauguen a, reck m, sandler ab, saijo n, johnson dh, et al. systematic review and meta-analysis of randomised, phase ii/iii trials adding bevacizumab to platinum-based chemotherapy as first-line treatment in patients with advanced non-small-cell lung cancer. ann oncol 2013; 24:20-30. 31. zinner rg, obasaju ck, spigel dr, weaver rw, beck jt, waterhouse dm, et al. pronounce: randomized, open-label, phase iii study of first-line pemetrexed + carboplatin followed by maintenance p e m e t r e x e d v e r s u s p a c l i t a x e l + c a r b o p l a t i n + bevacizumab followed by maintenance bevacizumab in patients with advanced nonsquamous non-small-cell lung cancer. j thorac oncol 2015; 10:134-42. 32. patel jd, socinski ma, garon eb, reynolds ch, spigel dr, olsen mr, et al. point break: a randomized phase iii study of pemetrexed plus carboplatin and bevacizumab followed by maintenance pemetrexed and bevacizumab versus paclitaxel plus carboplatin and 17. wu yl, yang jc, kim dw, lu s, zhou j, seto t, et al. phase ii study of crizotinib in east asian patients with ros1-positive advanced non-small-cell lung cancer. j clin oncol 2018; 36:1405-11. 18. lim sm, kim hr, lee js, lee kh, lee yg, min yj, et al. open-label, multicenter, phase ii study of ceritinib in patients with non-small-cell lung cancer harboring ros1 rearrangement. j clin oncol 2017; 35:2613-8. 19. planchard d, smit ef, groen hj, mazieres j, besse b, helland å, et al. dabrafenib plus trametinib in patients with previously untreated brafv600e-mutant metastatic non-small-cell lung cancer: an open-label, phase 2 trial. lancet oncol 2017; 18:1307-16. 20. reck m, rodríguez-abreu d, robinson ag, hui r, csőszi t, fülöp a, et al. pembrolizumab versus chemotherapy for pd-l1-positive non-small-cell lung cancer. n engl j med 2016; 375:1823-33. 21. lopes g, wu yl, kudaba i, kowalski d, cho bc, castro g, srimuninnimit v, et al. pembrolizumab (pembro) versus platinum-based chemotherapy (chemo) as first-line therapy for advanced/metastatic nsclc with a pd-l1 tumor proportion score (tps) ≥ 1%: openlabel, phase 3 keynote-042 study. j clin oncol 2018; 36s: asco #lba4. 22. gandhi l, rodríguez-abreu d, gadgeel s, esteban e, felip e, de angelis f, et al. pembrolizumab plus chemotherapy in metastatic non-small-cell lung cancer. n engl j med 2018; 378:2078-92. 23. paz-ares l, luft a, vicente d, tafreshi a, gümüş m, mazières j, et al. pembrolizumab plus chemotherapy for squamous non-small-cell lung cancer. n engl j med 2018; 379:2040-51. 2 4 . j o t t e r m , c a p p u z z o f, vy n n y c h e n k o i , stroyakovskiy d, abreu dr, hussein ma, et al. impower131: primary pfs and safety analysis of a randomized phase iii study of atezolizumab + carboplatin + paclitaxel or nab-paclitaxel vs carboplatin + nab-paclitaxel as 1l therapy in advanced squamous nsclc. j clin oncol 2018; 36s: asco #lba9000. 25. hellmann md, ciuleanu te, pluzanski a, lee js, otterson ga, audigier-valette c, et al. nivolumab plus ipilimumab in lung cancer with a high tumor muhammad kamran siddique al. 47jafmdc jan-june 2019;vol.1, no.1 non-small cell lung cancer 33. socinski ma, jotte rm, cappuzzo f, orlandi f, stroyakovskiy d, nogami n, et al. atezolizumab for first-line treatment of metastatic nonsquamous nsclc. n engl j med 2018; 378:2288-301. bevacizumab followed by maintenance bevacizumab in patients with stage iiib or iv nonsquamous non-smallcell lung cancer. j clin oncol 2013; 31:4349. muhammad kamran siddiqueal. 48jafmdc jan-june 2019;vol.1, no.1 author`s contribution dr. muhammad kamran siddique: concept of review, literature review, writing the initial draft of the manuscript and approving final version. dr. ehsan-ur-rahman: literature review, writing review, editing and approve final version. dr. muhammad saqib khan: concept of manuscript, literature review, manuscript writing and approve final version. page 40 page 41 page 42 page 43 page 44 page 45 page 46 j aziz fatm med den college july december 2020; vol. 2, no. 2 47 original article knowledge, attitude and practices survey: covid-19 pandemic and its preventive standard operating procedures in college students rabiya ali, muhammad jawad, alishba jawed, muhammad afzal , azka maryam zafar abstract objectives: to evaluate the knowledge, attitude and practices of the undergraduate college students towards corona virus disease (covid-19) and adoption of personal protective measures as per standard operating procedures (sops) stipulated by federal government for reopening of educational institute. methodology: this was cross sectional survey conducted at hyderabad and faisalabad based colleges form 25 september to 15 october 2020. prior to the study, permission was taken from principal of concerned colleges (vide no.tss/22/2021, kotri jamshoro) structured proforma comprised of 28 questions concerning knowledge, attitude and practices toward the covid-19 and implementation of sops in educational institutes was used. questionnaire was formed on google form and its link was shared among 200 college students of various disciplines through whatsapp. results from the response summary were compiled and analyzed. results: structured proforma was distributed among 200 undergraduate students of age range18-20 years, only 170 students’ submitted complete responses. response rate was 85%. more than half (70.9%) of the subjects have good knowledge and positive attitude concerning covid-19. majority of the students (89.2%) were using masks, 88.6% were in habit of regular hand washing ,while 84.3 % of students preferred to use sanitizers, 91.6% practiced social distancing and avoided crowded places ,75.3% students avoided unnecessary travelling. 98-99% of students agreed that sops set by government was strictly followed in the colleges. conclusion: majority of the students were aware of the preventive measures for covid outbreak. students have positive attitude and are adequately practicing precautionary measures to avoid contracting covid-19. sops are following in the colleges to alleviate the risk of spread of lethal corona. keywords: covid -19, college students, pandemic, standard operating procedures introduction corona virus disease (covid-19) is an emerging public health challenge around the world causing acute respiratory illness leading to high mortality and morbidity.1 it is caused by a novel coronavirus that is now named 'severe acute respiratory syndrome coronavirus 2' (sars-cov-2).2 this disease was emerged in wuhan, china in december 2019, spreading to many countries including pakistan and ___________________________________________________________ dr. rabiya ali, mbbs, mphil assistant professor karachi institute of medical sciences, cmh khi. muhammad jawad, ms lecturer punjab college fsd alishba jawed student 2nd year ics punjab college fsd muhammad afzal, ms lecturer national textile university fsd azka maryam zafar student 4year correspondence: dr. rabiya ali email: rabiya.rehan@gmail.com was declared a pandemic by the world health organization (who)3. according to an estimate by who, there have been 6,140,934 confirmed cases of covid-19, including 373,548 deaths across the globe till the writing of this article.4 the government of pakistan also confirmed 76,352 cases and 1,621 deaths till august 2020.5 whereas the active cases were 47,667 and total recoveries in pakistan were 27,110. healthcare workers (hcws) are frontline soldiers in this crisis, who also contracted the coronavirus and lost their precious lives to save their patients.6 in this worst situation, college students and their faculty members are also at risk of contracting the coronavirus in the pandemic chain as human-to-human transmission of covid-19 is due to of overcrowding in colleges. covid-19 crisis is an imminent threat for the public health and has posed as a challenge for research and medical communities. thus special efforts and attention to protect or decrease transmission should be applied in overcrowded areas like educational institutes. who and national command operation center pakistan (ncoc) have issued guidelines for preventing j aziz fatm med den college july december 2020; vol. 2, no. 2 48 further spread of covid-19. they recommend to avoid travelling to high-risk areas and contact with individuals who are infected with covid-19 or come from the endemic zone.4 travelers coming from abroad must be screened with thermal guns and are instructed to quarantine for 14 days.1,7 ncoc has also provided special guidelines for educational institutions to protect the students from this crisis. these guidelines aimed to mitigate risk while providing the opportunity to resume educational activity for children, adolescents and young adults during the covid-19 pandemic.8 these guidelines endorses maintaining social distances of about 6 feet, basic hand hygiene including frequent hand washing for 20 seconds and use of alcohol-based hand sanitizers. use of the personal protective equipment (ppe), such as face masks are recommended for the students as well as people interacting in extensive crowded settings like colleges and institutes where widespread community transmission can possibly occurr.8 environmental disinfection using appropriate disinfectants, such as bleach and sanitizers is also recommended to deactivate the coronavirus. covid positive students, staff or any person who has a positive contact-case at home are directed to stay at home and not attend the school or colleges to avoid spread of infection in other students.8 ncoc has made mandatory for all educational institutes to follow standard operating procedures (sops) while reopening the institutes, otherwise strict action will be taken for not following the sops.. 9 the ncoc has also performed an important role in educating the population about signs and symptoms of this pandemic. now it is our duty to follow these guidelines and to address them promptly. incorrect attitudes and practices augment the spread of this disease. this is likely to be intensified by the fact that college students have insufficient awareness for prevention and practices.10 awareness of the covid outbreak may influence college student’s attitudes and practices towards prevention of this disease. all appropriate precautions must be ensured by the college management and students to control the spread of infection. knowledge, attitudes, and practices (kap) of college students concerning covid virus and the factors that affect their attitudes and behaviors can be determined promptly during pandemic that helps in prioritizing protection and minimizing covid-19 exposure and spread. this study aims to investigate the kaps concerning covid-19 among young students and whether they are following the sops set by the government. methodology this cross-sectional survey included 170 under graduate college students belonging to intermediate colleges of hyderabad and faisalabad. prior to study, permission from the principal of the concerned colleges was taken (vide no.tss/22/2021, kotri jamshoro). the survey was carried out from 25 september to 15 october 2020, the period in which colleges were reopen after lock down. young students of the age group of 18-20 years who were willing to participate were enrolled in the study. the faculty members and other employees were excluded. the questionnaire comprised of total 29 questions regarding covid-19. twelve questions were related to knowledge, seven were related to attitude and ten were related to practices. all questions were prepared by the researchers using literature search from previous similar researches and ncoc guidelines.8 the proforma was circulated by means of google forms by sharing link on whatsapp among the study participants and the data was collected. the google doc had two parts. in the first part, participant had to consent only after which they were allowed to access the second part of questions related to covid survey where questions related to the knowledge, attitude and practice were asked. questions related to awareness concerning preventive and control measures of the infection such as wearing masks, importance of social distancing and hand hygiene etc. were inquired. the questionnaire link was sent to 200 college students. one hundred and seventy nine students responded, out of which 170 filled out complete proforma. students who filled complete proforma were included in this study. the data obtained from response summary of google form were compiled and statistically analyzed. results were presented as frequencies and percentages. results questionnaire was distributed among 200 male and female college students, of which only 170 submitted complete response. thus the response rate was 85%. out of total respondents,159 (93.5%) were females and 11(6.5%) were males. more than half of the participating students 98(57.64%) belonged to matric system, and 42.6% belonged to cambridge system. out of these, majority of the intermediate students 53(31.17%) were from pre medical, 41(24.1)% from to ics and 35(20.5)% from pre-engineering. a small number of students,2(1.17%) were from first year arts group, 4(2.35%)and 3(1.76%) were from i.com and a rabiya ali et al j aziz fatm med den college july december 2020; vol. 2, no. 2 49 levels respectively. while 32(18.8%) were belonged to others discipline. knowledge: small number of the study population (31.3%) knew that the sars-cov-2 was the virus responsible for corona infection, while 70.9% said that the covid disease could be transmitted by droplets when an infected person coughs, sneezes or speaks. most of the students (72.5%) were not satisfied with the government’s decision of reopening of the educational institutes and business activities without controlling corona cases. additionally, 80.8 % of the students believed that any type of group activity may spread this infection (table1). a good number of respondents (66.3%) believed that people travelling to the infected areas were more prone to get covid, while 69.9% believed that the subjects having exposure to infected person were more at risk. additionally 53.3% agreed that health workers are at higher risk of being infected. over all responses related to knowledge indicates that the majority of the students have adequate knowledge concerning spread and preventive measures of corona disease. attitude: of the total participants, 82.7% believed that corona outbreak can be managed by taking precautions and good practicing such as; avoiding crowded areas, wearing masks, washing hands and using sanitizers. more than half of the students (72.3%) understand that it is a highly contagious infection. similarly 85.6% of the participants realized that it is their responsibility to take safety measures for controlling the spread infection.(table.1) on enquiring about the mental wellbeing, 70.4% of subjects agreed that covid-19 had affected their social, mental and psychological well beings. only 53.3% of population was satisfied by government strategies for prevention of covid crisis. additionally 80% of the respondents believed that reopening of institutes in phases according to age groups with implementation of sops was good decision of the government. all respondents agreed to staying home when required and also any student, staff or person who has a positive contact-case at home should not be allowed to attend college.(table 1) practices: most of the of students (89.2%) were using masks, 88.6% washed hands regularly, 84.3% of students preferred to use sanitizers, 91.6% practiced social distancing and avoided crowded places,75.3% students avoided unnecessary travelling. (figure 1) (table 2) thus overall result indicates that majority of students have good practices concerning the adoption of the personal preventive measures. additionally, table 1. study participant’s knowledge and attitude concerning covid-19 pandemic. (n=170) questions yes (%) no (%) not sure/ neutral (%) knowledge covid-19 infection is caused by sars-cov-2. 31.8 59.7 8.6 covid-19 infection is spread via respiratory droplets of the infected person: 70.9 2.3 26.8 all community members are equally at risk for covid-19. 78.9 8.9 12.2 children can be infected with covid_19 84.6 6.1 9.3 it is a good decision to open educational institutes and business activities without controlling corona cases: 9.3 72.5 18.1 any type of group activity may spread this infection 80.8 66.1 14.7 closing teaching institutions and shopping malls are effective ways of social distancing 58.5 9.9 31.6 lockdown all over the country will control the spread of this virus 69.8 8.9 21.3 the best way of preventing spread of covid-19 is social distancing: 92.8 3 4.2 we can overcome this problem by taking precautionary steps: 82.7 0.3 17 advising quarantine to passengers coming from infected areas is a good practice to avoid spread of infection 77.5 5.9 16.6 isolation period for infected people and those exposed to infection is 14 days 56 23.2 20.8 attitude we can overcome this problem by taking precautionary steps 82.7 0 17.3 i understand that this infection is highly contagious 72.3 4.2 23.5 it is my social responsibility to take safety measures in controlling spread of this infection. 85.6 2.4 12 covid-19 is affecting my social, mental and psychological well beings: 70.4 29.6 0 i am satisfied with the government efforts for controlling this infection 53.3 17 29.7 reopening of institutes in phases according to age group is good decision of government: 80 5 15 did you agree: staying home when appropriate? any positive student, staff or any person who has positive contact-case at home will not allow to attend college 100 0 0 covid-19, a kap study j aziz fatm med den college july december 2020; vol. 2, no. 2 50 98-99% of students agreed that sops set by the government was strictly followed in the colleges such as shift arrangement of various classes, table 2: practices of standard operating procedures stipulated by ncoc questions yes (%) no (%) some times (%) i am avoiding meeting my friends and group fellows unnecessarily 47 7.1 45.8 i am avoiding to sit in crowded place in college 91.6 1.2 7.2 i prefer to walk by stairs then using lift 69 10.7 20.2 i am using face mask in college 89.2 2.4 8.4 i am using soap frequently for hand washing 91.7 3.2 5.1 thermal scanners are used in college for screening in college 99 1 0 various classes were divided into shifts in colleges 98 0 2 seat in class room are placed in at distance of 6 feet to maintain social distances, 99 0 1 students are divided into sections to avoid overcrowding in one class 99 0 1 class room are well ventilated 98.5 1 0.5 ncoc: national command operation center pakistan screening of the students and teachers by thermal guns on college entrance, ventilated classes with seating arrangements with 6 feet distance. it was mandatory for all teachers and student to wear mask in college figure:1 personal protective measures practiced by students campus. facilities for hand washing with soap were available in the colleges. frequent use of sanitizers was encouraged and sanitizers were provided by the college management. college floors were frequently disinfected for the provision of healthy and safe environment (table2) discussion the second wave of corona infection has started and rapidly spread throughout the world due to person to person transmission.11corona virus pandemic has severely stuck the educational system in pakistan. some institutes started online classes during this crisis to acquire quality education from home during the lockdown. however it is not possible for many of government and private schools/colleges to provide this digital platform for their students thus resulting in educational loss. therefore, federal and provincial governments decided to reopen educational institutes in phases, according to age groups with sops in order to restore the educational activities.8,9 however it is also necessary to control this fatal disease and to avoid its rapid transmission. ncoc pakistan has provided special health guidelines and sops that were made mandatory to be implemented in educational institutes for safe learning environment and protection of students and their families from covid-19. primary preventive measures stipulated by who and ncoc pakistan includes regular hand washing, social distancing, and use of mask ensuring respiratory hygiene by covering mouth and nose while coughing or sneezing.9,12 people’s adherence to preventive and control measures are crucial for effective corona outbreak control. this adherence is highly dependent on the populations’ knowledge, attitudes, and practices (kap) towards covid-19. this study was conducted to evaluate the knowledge, attitude and practices of the intermediate college students towards covid infection and adoption of personal protective measures as per sops set by the government for reopening of educational institutes. majority of participating students in the study were from matric system while only one third were from the cambridge system. intermediate students of pre medical, ics , pre engineering, fa and students of a level recorded their responses. in this study females submitted greater responses than males. in current study 70.9% had adequate knowledge about the mode of transmission of covid 19 and they knew that it is spread via respiratory droplets of the infected person and 69.9 % agreed that the non-infected subjects having contacts with infected patients were more susceptible for getting corona disease. better results were reported by a similar study conducted in karachi, documenting that according to 85.5% of participants most common mode of transmission for covid-19 was respiratory droplet of the infected person. whereas 89.65% of the participants believed that covid infection was frequently transmitted from an infected person to a non-infected person, these findings are in accordance with current results.13 ngwewondo et al reported that 84.19% of females participants of their study had adequate knowledge concerning covid-19 mode of transmission.11present results concerning attitude of students shows that 72.3% of the students understand rabiya ali et al j aziz fatm med den college july december 2020; vol. 2, no. 2 51 that covid-19 is highly contagious in nature and unpredictable, while 23.5% were neutral and 4.2 % disagreed with this fact. our results also revealed that 53.3% of the study subjects were satisfied with measures introduced by the government and appreciated their mitigation strategies for controlling the infection. similar results have been reported by ahmad et al study conducted at karachi, documenting that 56.7% of their study population was satisfied with local and provincial governments strategies for controlling the risk of covid-19.13 majority of the responses related to attitude shows positive trend in students in this outbreak. in developing countries like pakistan with poor health infrastructure and educational system, population gets negative impact on the psychological and social wellbeing. results of current study showed that more than half of the students (70.4%) have negative psychological impacts of lockdown resulting in closure of the educational institutes and suppression of economical activity. inconsistent results have been reported by ahmed et al that documented, 32.3% of their young respondents felt isolated and depressed as a consequence of pandemic.13 due to the lock down, parents are facing financial constraint but they are paying heavy college fees despite of closed institutes. additionally, they are also paying internet charges, required for online classes. all above mentioned factors attributes to stress and depression in the parents as well as students. concerning the practices of protective measures, wearing of face mask was practiced by 89.2 % of students while 8.4% sometimes used mask and 2.4% do not use mask. for ensuring hand hygiene, 91.7% of population washed hands frequently, 91.6 % avoided going in crowded places and practiced social distances. in contrast to our study , a study conducted at cameroon, central africa showed better practices and reported that 100% of the population wore masks, 83.8% of their study population practice social distancing, or avoid crowded places, while 20% were restricted at the home and 94.5% of the cameroon participants frequently washed hand with soap and used sanitizers for hand hygiene.11 study conducted at mangalore in coastal south india evaluating the knowledge and practices of undergraduate student towards covid also reported that 98.3% of the students adopted the habit of hand washing specially in public places.10 in contrast to our study, good practices have been adopted by the chinese population as stated by zhong et al, reporting that 95-97% of population has adopted the preventive measures such as avoiding the crowded areas and wearing a mask when going outside.14 study from karachi also reported better practices than current results.13 concerning the implementation of the sops for covid-19 prevention, current results shows that 98-99% of the students agreed that in colleges all preventive measures were being implemented as per sops defined by government. students and teachers were screened by thermal guns at entry point of the college, and those with fever or any symptoms were not allowed to enter the college and were encouraged to stay at home. classes of various disciplines were arranged in shifts, class rooms were well ventilated and seats were placed at 6 feet distance for ensuring social distancing. it was mandatory for all teachers and student to wear mask in college campus. facilities for hand washing and sanitizers were available in colleges. efforts of the local, provincial and federal governments and managements of the educational institutes are highly appreciated for implementation of mitigation strategies for avoiding the spread of this lethal global health crisis, while reopening of the educational organizations and safer restoration of educational activities. government and various non-government organizations can plan more public health strategies to reduce the burden of this global public health challenge. limitations:the main limitation of this study was that study population was restricted to only undergraduate college students. it would have been better if the present results could have been compared with graduate students. strength:the strength of this study lies in the fact that it provides a “real-time” assessment of the knowledge, attitudes and practices of college students during ongoing crisis, which helps policy makers to plan and provide an efficient and effective strategies to overcome covid outbreak. conclusion majority of the students were aware of the preventive measures to be followed during the covid outbreak. students have a positive attitude and are adequately practicing the safe precautionary measures to avoid contracting covid-19. sops are being followed in the colleges to alleviate the risk of spread of lethal corona virus. funding source: none. conflicts of interest: none. covid-19, a kap study j aziz fatm med den college july december 2020; vol. 2, no. 2 52 references 1. guidelines to implement preventive health measures for passengers, conveyances and cargo at ground crossings. 2020; code 28-02: version 02. http://covid .gov .pk/new_ guidelines/27june2020_20200627_guidelines_to_impleme nt_preventive_health_measures_for_passengers_2802.pdf [cited on: june ,15, 2020] 2. olum r, chekwech g, wekha g, nassozi dr, bongomin f. coronavirus disease-2019: knowledge, attitude, and practices of health care workers at makerere university teaching hospitals, uganda. frontiers in public health. 2020;8(181) doi: 10.3389/fpubh.2020.00181 3. abbas z, zaheer r. clinical insight into the involvement of gut and liver by covid-19. j pak med assoc. 2020;70(6):952-953. 4. who coronavirus disease (covid-19) dashboard data last updated: 2020/6/2 https://covid19.who.int/?gclid=eai aiqobchmi0igwzpbj6qivzrvvch2zhaaneaayas aa egkjvfd_bwe, [cited on: august 2 , 2020] 5. government of pakistan,offical portal. http://covid.gov.pk/ [cited on:august 2 , 2020) 6. zhang m, zhou m, tang f, wang y, nie h, zhang, l, et al. knowledge, attitude, and practice regarding covid-19 among healthcare workers in henan, china. j hosp infect. 2020; 105(2):183–187. doi: 10.1016/j.jhin.2020.04.012 7. sohrabi c, alsafi z, o'neill n, khan m, kerwan a, al-jabir a, et al. world health organization declares global emergency: a review of the 2019 novel coronavirus (covid19). int j surg. 2020; 76:7176. doi:10.1016/ j. ijsu . 2020.02.03 8. govt. of pakistan. health guidelines for education institutions reopening during covid 19 pandemic. 2020; code:36-02version02. https:// covid.gov.pk/new_ guidelines/ 10september2020_20200909_health_guidelines_for_educ ation_institutions_reopening_during_covid_19_pandemi c_3603.pdf [cited on : september 15 , 2020] 9. ali m. educational institute to reopen countrywide in phases from september 15. dawn. updates 8 sep 2020. https: // www. dawn.com/news/1578399 [cited on: sept, 9; 2020] 10. deeksha das, ramya shenoy, megha mukherjee bhaskaran unnikrishnan, nikita rungta. awareness among undergraduate students of mangalore city regarding novel coronavirus (covid-19): a questionnaire study disaster med public health prep. 2020; 24 : 1-4.doi: 10. 1017/ dmp. 2020.204 11. ngwewondo a, nkengazong l, ambe la, ebogo jt, mba fm, goni ho ,et al. knowledge, attitudes, practices of/ towards covid 19 preventive measures and symptoms: a cross-sectional study during the exponential rise of the outbreak in cameroon. plos negl trop dis. 2020;14(9) : e0008700.doi: 10.1371/journal.pntd.0008700. 12. world health organization (who). report of who china joint mission on coronavirus disease 2019 (covid 19). 2020. 13. ahmed n , hassan w , rasool r , fahim u , shakil a, khan ks. knowledge, attitude and practices regarding covid-19 among a cross-sectional sample from karachi, pakistan: descriptive data , j infect dis epidemiol 2020, 6(5):164 doi: 10.23937/2474-3658/1510164. 14. zhong bl, luo w, li hm, zhang qq, liu xg, li wt et al. knowledge, attitudes, and practices towards covid-19 among chinese residents during the rapid rise period of the covid-19 outbreak: a quick online cross-sectional survey. int j biol sci. 2020;16:1745-1752. author’s contribution: dr. rabiya ali muhammad jawad alishba jawed muhammad afzal azka maryam zafar study design, acquisition of data and manuscript write up. reviewed and approved the manuscript. study design, manuscript writing, reviewed and approved the manuscript. data collection, manuscript writing, compiling and analysis of data, interpretation of results, formulate tables. reviewed and approved the manuscript. study design, data analysis write up and interpretation of results. revising manuscript critically for important intellectual content data collection, revised manuscript and approved it. all authors are responsible for research work, data integrity and the accuracy received: 1 nov 2020, revised received: 15 dec 2020, accepted: 25 dec 2020 rabiya ali et al https://dx.doi.org/10.3389%2ffpubh.2020.00181 https://covid19.who.int/ https://www.ncbi.nlm.nih.gov/pubmed/?term=zhang%20m%5bauthor%5d&cauthor=true&cauthor_uid=32278701 https://www.ncbi.nlm.nih.gov/pubmed/?term=zhou%20m%5bauthor%5d&cauthor=true&cauthor_uid=32278701 https://www.ncbi.nlm.nih.gov/pubmed/?term=tang%20f%5bauthor%5d&cauthor=true&cauthor_uid=32278701 https://www.ncbi.nlm.nih.gov/pubmed/?term=wang%20y%5bauthor%5d&cauthor=true&cauthor_uid=32278701 https://www.ncbi.nlm.nih.gov/pubmed/?term=nie%20h%5bauthor%5d&cauthor=true&cauthor_uid=32278701 https://www.ncbi.nlm.nih.gov/pubmed/?term=zhang%20l%5bauthor%5d&cauthor=true&cauthor_uid=32278701 https://www.ncbi.nlm.nih.gov/pubmed/?term=you%20g%5bauthor%5d&cauthor=true&cauthor_uid=32278701 https://www.ncbi.nlm.nih.gov/pmc/articles/pmc7194961/ https://dx.doi.org/10.1016%2fj.jhin.2020.04.012 https://www.ncbi.nlm.nih.gov/pubmed/?term=das%20d%5bauthor%5d&cauthor=true&cauthor_uid=32576311 https://www.ncbi.nlm.nih.gov/pubmed/?term=shenoy%20r%5bauthor%5d&cauthor=true&cauthor_uid=32576311 https://www.ncbi.nlm.nih.gov/pubmed/?term=mukherjee%20m%5bauthor%5d&cauthor=true&cauthor_uid=32576311 https://www.ncbi.nlm.nih.gov/pubmed/?term=unnikrishnan%20b%5bauthor%5d&cauthor=true&cauthor_uid=32576311 https://www.ncbi.nlm.nih.gov/pubmed/?term=unnikrishnan%20b%5bauthor%5d&cauthor=true&cauthor_uid=32576311 https://www.ncbi.nlm.nih.gov/pubmed/?term=rungta%20n%5bauthor%5d&cauthor=true&cauthor_uid=32576311 https://www.ncbi.nlm.nih.gov/pmc/articles/pmc7373826/ https://www.ncbi.nlm.nih.gov/pmc/articles/pmc7373826/ https://dx.doi.org/10.1017%2fdmp.2020.204 https://dx.doi.org/10.1017%2fdmp.2020.204 https://pubmed.ncbi.nlm.nih.gov/32886678/ https://pubmed.ncbi.nlm.nih.gov/32886678/ https://pubmed.ncbi.nlm.nih.gov/32886678/ https://pubmed.ncbi.nlm.nih.gov/32886678/ https://pubmed.ncbi.nlm.nih.gov/32886678/ https://www.ncbi.nlm.nih.gov/pmc/articles/pmc7098034/ https://www.ncbi.nlm.nih.gov/pmc/articles/pmc7098034/ https://www.ncbi.nlm.nih.gov/pmc/articles/pmc7098034/ https://www.ncbi.nlm.nih.gov/pmc/articles/pmc7098034/ https://www.ncbi.nlm.nih.gov/pmc/articles/pmc7098034/ july december 2019; vol. 1, no. 2 j aziz fatm med den clg 70 review article the surgical management of haemorrhoids – a historical perspective keval patel, samuel stefan, syed naqvi, jim. s. khan summary haemorrhoids have affected people since ancient time. first documented treatment for haemorrhoids reported from the egyptian papyrus. indeed, ebers’ papyrus dated at 1550 bc, described the use of topical astringents to ease haemorrhoidal pain. more recently, the milligan-morgan haemorrhoidectomy and office procedures such as rubber-band ligation have been developed to improve patients’ symptoms. however, these treatments have accompanying problems, for example the haemorrhoidectomy is known to be a profoundly painful operation and office procedures have high recurrence rates and are only suitable for minor haemorrhoids. the development of stapled haemorrhoidopexy and transanal haemorrhoidal dearterialisation (thd) procedures, present the opportunity to treat all grades of haemorrhoids, with improved post-operative pain, whilst maintaining a low recurrence rate. this article places these more modern techniques in the context of the long history of surgical treatments for haemorrhoids and reviews the latest literature comparing operative haemorrhoidectomy, stapled haemorrhoidopexy and thd. a systematic review was carried out to retrieve articles describing history of surgical management of haemorrhoids and studies comparing three modern treatments for haemorrhoids (haemorrhoidectomy, stapled haemorrhoidectomy, and thd) were reported. keywords: haemorrhoids, stapled haemorrhoidectomy, transanal haemorrhoidal dematerialization. introduction this review article summarises the studies presenting history of surgical management of haemorrhoids. a pubmed search was carried out with the key words of haemorrhoids, history, and surgery and article reporting historical management of haemorrhoids. references in these papers were manually checked and explored for further information. three surgical modalities for the management of haemorrhoids (haemorrhoidectomy, stapled haemorrhoidectomy and thd) were analysed in detail and studies presenting clinical outcomes of these methods were included in this review. first documented treatment for haemorrhoids comes from the egyptian papyrus. edwin smith in 1700 bc ____________________________________________________________ dr. keval patel (mrcs) specialist trainee portsmouth hospitals nhs trust, uk dr. samuel stefan (mrcs) clinical fellow portsmouth hospitals nhs trust, uk dr. syed naqvi (frcs) consultant surgeon portsmouth hospitals nhs trust, uk dr. jim. s khan (phd, frcs) consultant surgeon portsmouth hospitals nhs trust, uk honorary reader anglia ruskin university, cambridge, uk correspondence: dr. jim. s khan email: jim.khan@porthosp.nhs.uk describe the use of an ointment of great protection made of acacia leaves, ground, titurated and cooked together, smear a strip of fine linen there with and place in the anus, that was helpful in treating haemorrhoid.1 other archaeological artifacts also depict the struggle faced by early surgeons in relieving the symptoms of haemorrhoids. indeed, the ebers’ medical papyrus, dated at 1550 bc outlines the use of topical astringent lotions to treat haemorrhoids.2 around 400bc hippocrates published his treatise “on haemorrhoids” where he described the perceived pathophysiology of haemorrhoids (the improper distribution of bile and phlegm to the anal veins) and a surgical means to their remedy.3 hippocrates suggested several techniques to cure the patient of their haemorrhoids. one method was to apply seven to eight heated iron rods to the “forced out anus.” hippocrates was clearly concerned with recurrence as, in his treatise he described that the anus should be forced out as much as possible to ensure that no haemorrhoidal tissue remains.2 of note, hippocrates was the first to document use of a speculum to inspect the anal canal. additionally, hippocrates suggested the use of an assistant to hold down the arms and legs of the patient as he found the pain produced during the procedure helpful, due to patients’ tendency to strain after the start of treatment, thus aiding the surgeon in removal of haemorrhoidal tissue in its entirety.3 hippocrates was also concerned with post-operative care and detailed the preparation of boiled lentils and mailto:jim.khan@porthosp.nhs.uk july december 2019; vol. 1, no. 2 j aziz fatm med den clg 71 tares (a weedy plant) for topical application postoperatively. similar descriptions of operations have been found in the scripts of ancient cultures from across the globe.2 in the late 2nd century galen, a roman physician described using a thread to tie off piles (likely to be the external portion of haemorrhoids only) resulting in shriveling and necrosis of the external haemorrhoid.2 additionally, indian texts written in the 4th and 5th centuries describe the use of clamps and cautery for the operative treatment of haemorrhoids.1,2 the indian susruta samhita, an ancient sanskrit text dated between the fourth and fifth century ad, described treatment procedures comparable to those in the hippocratic treatise, but with advancement in surgical procedures and emphasis on wound cleanliness.1 operative technique of choice of some ancient surgeons were the circumferential ligature, encompassing the haemorrhoidal tissue. however, other eminent surgeons’ use of sharp dissection and/or cautery of haemorrhoids.2 for the subsequent millennium there would be few major advances in the operative treatment of haemorrhoids, save john of arderne’s, treatise on haemorrhoids and fistula-in-ano in the 14th century. arderne recognised that haemorrhoids could vary in their severity and classified them into internal and external haemorrhoids.2 furthermore, arderne documented the need for different treatment methods for each type, a strategy that remains in use today.1 in 1892, mathews advocated the use of one part phenol, two parts olive oil as an injectable sclerosant to treat symptomatic haemorrhoids.4 the sclerosant was to be injected to the haemorrhoidal pedicle, creating a fibrous reaction that would destroy the haemorrhoidal blood supply, causing haemorrhoidal tissue to necrose then slough away with faecal movement.5 sclerosant injection has been common place for over a century and varying compositions of sclerosant have been proposed. currently, 5% phenol dissolved in peanut oil is the most commonly used in the uk.4 however, sepsis, retroperitoneal abscesses and urological complications have all been reported following injection. despite this, a recent survey of colorectal surgeons found that sclerosant injection is the treatment of choice for 1st degree haemorrhoids.5 operative haemorrhoidectomy it wasn’t until 1935 that milligan and morgan described their eponymous haemorrhoidectomy, as a treatment for large 2nd, 3rd and 4th degree haemorrhoids. the operation involves dissection of the internal and external haemorrhoidal tissue (including the pedicle) in addition to ligation of the haemorrhoidal artery in order to reduce the rate of recurrence. milligan and morgan described the necessity of maintaining “at least a ¼ inch of anal mucous membrane and skin” as a mucosal bridge between haemorrhoids to aid re-epithelialization and prevent stricture formation.6 soon after, ferguson and heaton developed the “closed haemorrhoidectomy”.7 their description involves careful preoperative preparation, with a fluid diet for the preceding day and a strict regimen of laxatives and enemas administered to empty the rectum. the operative dissection is similar to that described by milligan and morgan however, the key difference is the retention of the length of the pedicle stitch, which is later used to close the anal mucosa and skin. this procedure is postulated to result in reduced post-operative pain and an earlier return to work and is therefore popular amongst surgeons in the usa.6,7 that conventional surgical teaching dictates anal wounds should never be closed, has led many surgeons to question whether the ferguson haemorrhoidectomy resulted in an increased rate of post-operative infection and therefore increased post-operative pain.7 indeed the choice of open vs. closed haemorrhoidectomy remains a topic of much debate, with some studies showing improved post-operative pain in closed haemorrhoidectomies8, some studies finding no difference9,10 and others favoring the open haemorrhoidectomy.11 recent modifications to the haemorrhoidectomy allow for the use of point diathermy12, laser13, ligature 14,15 and harmonic scalpel.16 however, despite these modifications, operative principles have remained unchanged. thus, the excisional haemorrhoidectomy became the unchallenged gold-standard operation for 3rd and 4th degree haemorrhoids for the majority of the 20th century, with the milligan-morgan (mm) haemorrhoidectomy remaining popular in the uk and the closed haemorrhoidectomy commonly used throughout the usa.6 despite the haemorrhoidectomy being the gold standard treatments for haemorrhoids, bleday et al.17 recommended that just under 10% of haemorrhoidal patients presenting to colorectal surgeons should be offered haemorrhoidectomy and it should be only offered to patients with 3rd and 4th haemorrhoids. this is in part due to the significant complication and morbidity rates associated with haemorrhoidectomy. traditional haemorrhoidectomy has been associated with a low rate of recurrence. indeed, van de stadt18 followed up 507 patients for 46 months post mm haemorrhoidectomy, finding none that required further surgery in that time. additionally, reported hemorrhage rates following conventional keval patel et al. july december 2019; vol. 1, no. 2 j aziz fatm med den clg 72 haemorrhoidectomy are low. indeed, a prospective follow up of 1,988 patients showed that bleeding occurred in only 8.4% of cases, with major hemorrhage, requiring further surgery accounting for only 2.4% of the total number of cases.17 however, conventional haemorrhoidectomy is also known for being notoriously painful and, some argue, the reason that many patients avoid consulting their colorectal surgeon19. indeed, as many as 28.8% of patients complain about significant post-operative pain following open haemorrhoidectomy.20 though many methods have been suggested to reduce post-operative pain, for example lateral sphincterotomy20, metronidazole7, anal dilation21, etc., post-operative pain remains a significant concern following conventional haemorrhoidectomy. office procedures more recently still, there has been an upsurge of interventional treatments for haemorrhoidal disease, targeted at avoiding formal haemorrhoidectomy and its associated pain. rubber band ligation was first described by blaisdell in 1958, whereby a rubber band is placed on the pedicle of the haemorrhoidal tissue above the dentate line, resulting in necrosis of haemorrhoidal tissue and its eventual sloughing, akin to the threads used by galen, thereby alleviating the patients’ symptoms. rubber bands replaced the traditional ligature as they could maintain pressure on the haemorrhoidal pedicle for longer periods and thus, reduced the incidence of post-operative bleeding22. barron later modified blaisdell’s technique by introducing the barron ligator, enabling a quick interchange of bands. the rubber band ligation of haemorrhoids could be performed in seconds and without the need for general anesthetic, significantly reducing the anxiety, pain and apprehension of patients when visiting a colorectal surgeon19. however, rubberbands are extremely painful if placed below the dentate line and cannot deal with the cutaneous portion of the haemorrhoid. continuing the search for “office” based treatments for haemorrhoids, lewis (1969) suggested that cryotherapy could be utilized to treat haemorrhoids. he described using nitrous oxide for internal haemorrhoids and liquid nitrogen for the skin component. neither treatment required sedation nor analgesia and treatment occurred in the office setting. however, in addition to a high recurrence rate, haemorrhoidal oedema severe enough to warrant admission was reported following cryotherapy. infrared coagulation was proposed by neiger in 1979. by using a pulse of infrared radiation to the base of the haemorrhoidal pedicle (where sclerosant would be injected for injection treatment of haemorrhoids), immediate shriveling of the haemorrhoids resulted, therefore avoiding the swelling associated with cryotherapy whilst still achieving office based treatment of haemorrhoids. despite this, infrared coagulation often requires more secondary treatment than rubber-band ligation therapy.23 despite the many advantages of “office” procedures to treat haemorrhoids, their success rates remain low, with some studies quoting long-term failure rates of 30% for the treatment of internal haemorrhoids by rubber band ligation23-25 and even higher recurrence rates for sclerotherapy and infrared coagulation.23, 26 stapled haemorrhoidopexy: in 1998, longo introduced the stapled procedure for prolapse and haemorrhoids (pph), otherwise known as stapled haemorrhoidopexy.27 by using a circular stapling device to ligate and remove haemorrhoidal mucosa, external haemorrhoidal tissue would be retracted back into the anal canal, whilst concurrently interrupting haemorrhoidal blood supply and causing necrosis of the remaining haemorrhoidal tissue. consequently, stapled haemorrhoidopexy is suitable for the treatment for 3rd and 4th grade haemorrhoids as well as smaller haemorrhoids. as no anal canal scars are left exposed, patients can expect to experience less post-operative pain than conventional haemorrhoidectomy and hence, an earlier return to work.28,29 indeed, recent meta-analysis of 29 rct’s revealed that post-operative pain control at 24 hrs is better in stapled haemorrhoidopexy than conventional haemorrhoidectomy30 and a meta-analysis of 10 trials showed an earlier return to work for patients undergoing stapled haemorrhoidopexy compared with those undergoing conventional haemorrhoidectomy. additionally, meta-analyses of 6, 9 and 13 rcts showed statistically significantly shorter operative time for stapled haemorrhoidopexy when compared to conventional haemorrhoidectomy.30,31,32 additionally, several individual rct’s show an improvement in outcomes for incontinence with stapled haemorrhoidopexy.33-37 despite this, three separate meta-analysis of 7, 18 and 4 rct’s, could not demonstrate statistically significant difference for incontinence rates between patients undergoing stapled haemorrhoidopexy and conventional surgery. several studies have reported that stapled haemorrhoidopexy confers an increased risk of early or peri-operative bleeding when compared with conventional surgery.34 indeed, nisar et al.32 meta-analysis of 7 rct’s surgical management of haemorrhoids july december 2019; vol. 1, no. 2 j aziz fatm med den clg 73 indicated a statistically significant reduction in perioperative bleeding for patients undergoing traditional surgery. additionally, shao et al.31 found that early post-operative bleeding was more likely following stapled haemorrhoidopexy than conventional haemorrhoidectomy in a meta-analysis of 21 rct’s. indeed shao et al.31 found that several rct’s described the need for additional suture material to the staple line. despite this difference in early post-operative bleeding, laughlan et al.’s30 meta-analysis of 21 rct’s showed no statistically significant difference when pooling, short (<1month), medium (>1month and <36 months) and long-term (36 month) bleeding outcomes, postulating therefore, that bleeding risk must be reduced with stapled haemorrhoidopexy in the longterm, to account for the equality in total bleeding found by their systematic review. higher recurrence rates have been reported following stapled haemorrhoidopexy patients when compared to conventional haemorrhoidectomy. indeed, nisar et al.32 found recurrence rates to be higher for stapled haemorrhoidopexy after an average follow up of 15.9 months in a meta-analysis of 9 rct’s (11.8% vs. 0% for 3rd degree haemorrhoids and 50 vs. 0 for 4th degree haemorrhoids). similarly, in a meta-analysis of 21 studies, shao et al.31 found recurrent prolapse rates to be almost twice as high following stapled haemorrhoidopexy than after conventional surgery, in addition, they report an increased need for surgery though this did not reach statistical significance.31 therefore, though stapled haemorrhoidectomy offers some advantages, i.e. that it allows for day surgery treatment, reduced post-operative pain and an earlier return to work, it has a higher recurrence rate than traditional surgery. furthermore, martisons et al.29 remind us that stapled haemorrhoidopexy is unable to treat concomitant peri-anal disease e.g. fissures, skin tags, etc., without requiring further surgery or an additional procedure, thereby negating some of the benefits of stapled haemorrhoidopexy. doppler guided haemorrhoidal artery ligation the previously described high failure rates of office treatments for haemorrhoids may be due to the novel understanding of the role of arterial flow in the pathogenesis of haemorrhoids24. sun et al.38 describe how haemorrhoidal vascular hyperplasia leads to distension of the vascular plexus. destruction of the muscular and connective tissue then follows, resulting in further vascular in-flow and out-flow imbalance and consequently, further laxity of haemorrhoidal connective tissue. however, giordano et al.39 argue that the precise initiating mechanisms of haemorrhoids remain controversial. they argue that vascular hyperplasia, internal anal sphincter tone, connective tissue degeneration, impaired venous drainage, arteriovenous shunts within haemorrhoidal vasculature, or a combination of the above reasons could each initiate haemorrhoidal disease. however, several studies have shown that vascular hyperplasia has been shown to have a significant role in haemorrhoidal development38 and giordano et al.39 concede that reducing blood flow to haemorrhoidal tissue may result in haemorrhoidal shrinkage and consequently, symptomatic improvement. in 1995, morinaga et al.40 described using a miniature doppler probe to identify the haemorrhoidal artery, developing the “doppler guided haemorrhoidal artery ligation” (dghal), also known as the transanal haemorrhoidal dearterialisation (thd). during thd, a modified ultrasound probe is used to identify the branches of the superior haemorrhoidal artery. upon doppler identification, ligatures are used, through a window in the probe, to tie off the arteries 2-3cm above the dentate line39. an average of five superior rectal artery branches require ligation, though the true number of contributing arteries can range from one to eight vessels41. despite the operation revolving around the ligation of arterioles, post-operative bleeding rates for thd appear to be low, with giordano et al.39 reporting an early post-operative bleeding rate of only 4.3% (86/1986) in a systematic review of 17 rct’s. additionally, giordano et al.39 report an incontinence rate of 0.4% (3/693) and that 1st day post-operative pain was only present in 18.5% of patients (353/1905)39. indeed, return to work was swift with patients taking on average only 2-3 days of recuperation prior to recommencing work39.additionally, giordano et al.39 report a 9.0% recurrence rate overall (96/1065) however, the rct’s reviewed had variable periods of follow up, ranging from 3-79 months. of these, dal monte et al.42 had the longest patient follow up, ranging from 22-79 months. despite this, they too reported recurrence rates of 8.7% (19/219 patients)42, indicating consistency amongst reported recurrence rates (at approximately 9%) for patients undergoing thd. however, failure rates are considerably higher in grade iv haemorrhoids43 for example, scheyer et al.44, found 59.3% recurrence rate (16/27 patients) for patients with 4th degree haemorrhoids at 18 month follow up and dal monte et al.42 found a recurrence rate of 26.7% for patients with 4th grade haemorrhoids at a mean follow up of 46months. therefore, giordano et al.39 concluded that thd was safe and efficacious in treating 2nd and keval patel et al. july december 2019; vol. 1, no. 2 j aziz fatm med den clg 74 3rd degree haemorrhoids but, not for 4th degree haemorrhoids. comparison studies these novel techniques represent exciting innovations in the treatment of an age old problem. indeed, several studies have attempted to compare and contrast the benefits of thd versus stapled haemorrhoidopexy. figure 1: transanal haemorrhoid artery dearterialisation approach https://synapse.koreamed.org/viewimage.php?type=f&aid=1114 6&id=f2&afn=37_jkss_79_2_116&fn=jkss-79-116g002_0037jkss figure 2: stapled haemorrhoidectomy https://www.mdedge.com/ccjm/article/206851/gastroenterology/he morrhoids-range-treatments/page/0/3 festen et al.45 describe a rct of 41 patients allocated to either thd or stapled haemorrhoidopexy, concluding that thd and stapled haemorrhoidopexy provide similarly low recurrence rates in the short-term (measured by a resolution of symptoms 6 weeks postoperatively). however, as teo et al.46 point out, festen et al.45, had few patients in each group, mismatched haemorrhoidal severity between the groups and furthermore, had followed up patients for only six weeks. despite these failures, other recent publications of abstracts presented at conferences corroborate festen et al.45 initial findings. indeed, altomare et al.47 report early results of an rct consisting of 172 patients and, they too found reduced post-operative pain in the initial post-operative week for patients undergoing thd, whilst finding similar recurrence rates between thd and stapled haemorrhoidopexy after a mean follow up of 15 months. conclusion haemorrhoids have afflicted humans for millennia and their treatment has been notoriously painful. through surgical innovation, novel approaches to the pre, intra and postoperative management of haemorrhoids have greatly improved patients experience of the disease. traditional treatment options have varied, with some providing good post-operative pain control, early return to work and high patient satisfaction48,49, whilst others provided a low recurrence rate23. however, that one particular treatment is not widely accepted implies that none are likely to be significantly more efficacious than its counterparts. therefore, innovative treatments are sought that will once again change the face of surgical management of this longstanding disease. stapled haemorrhoidopexy and transanal haemorrhoidal dearterialisation may deliver such promises. indeed, both techniques give short-term benefits in terms of reduced post-operative pain and increased suitability for day-case surgery and hence have increased in popularity. however, recurrence rates remain higher than traditional haemorrhoidectomy and robust evidence, with high quality studies conducted with long-term follow up, particularly for thd, are required. conflicts of interest: none. references 1. agbo sp.surgical management of hemorrhoids. j surg tech case rep. 2011; 3(2):68-75. doi: 10.4103/20068808.92 2. ellesmore s, windsor ac. surgical history of haemorrhoids. in mann c.v. (eds) surgical treatment of haemorrhoids. springer; london. 2002;1924. doi.org/ 10.1007/978-1-4471-3727-6_1. surgical management of haemorrhoids https://synapse.koreamed.org/viewimage.php?type=f&aid=11146&id=f2&afn=37_jkss_79_2_116&fn=jkss-79-116-g002_0037jkss https://synapse.koreamed.org/viewimage.php?type=f&aid=11146&id=f2&afn=37_jkss_79_2_116&fn=jkss-79-116-g002_0037jkss https://synapse.koreamed.org/viewimage.php?type=f&aid=11146&id=f2&afn=37_jkss_79_2_116&fn=jkss-79-116-g002_0037jkss https://www.mdedge.com/ccjm/article/206851/gastroenterology/hemorrhoids-range-treatments/page/0/3 https://www.mdedge.com/ccjm/article/206851/gastroenterology/hemorrhoids-range-treatments/page/0/3 https://www.ncbi.nlm.nih.gov/pubmed/22413048 july december 2019; vol. 1, no. 2 j aziz fatm med den clg 75 3. adams f. on hemorrhoids by hippocrates. adelaide: ebooks@ adelaide; 2007. available from: http://ebooks . adelaide.edu.au/h/hippocrates/hemorrhoids/. 4. mathews jm. a treatise on the disease of the rectum, anus and sigmoid flexure. 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koç d, i̇nceoğlu r. hemorrhoidectomy: open or closed technique? diseases of the colon &amp; rectum. 2002;45(1):70-75. 12. andrews bt, layer gt, jackson bt, nicholls rj. randomized trial comparing diathermy hemorrhoidectomy with the scissor dissection milligan-morgan operation. dis colon rectum. 1993;36(6):580-583. 13. wang jy, chang-chien cr, chen js, lai cr, tang rp. the role of lasers in hemorrhoidectomy. dis colon rectum. 1991; 34(1):78-82. 14. jayne dg, botterill i, ambrose ns, brennan tg, guillou pj, o'riordain ds. randomized clinical trial of ligasure™versus conventional diathermy for day-case haemorrhoidectomy. british journal of surgery. 2002;89(4):428-432. 15. nienhuijs s, de hingh i. conventional versus ligasure hemorrhoidectomy for patients with symptomatic hemorrhoids. cochrane database syst rev. 2009(1):cd006761. 16. tan j, seow-choen f. prospective, randomized trial comparing diathermy and harmonic scalpel® hemorrhoidectomy. diseases of the colon &amp; rectum. 2001;44(5):677-679. 17. bleday r, pena jp, rothenberger da, goldberg sm, buls jg. symptomatic hemorrhoids: current incidence and complications of operative therapy. dis colon rectum. 1992;35(5):477-481. 18. van de stadt j, d'hoore a, duinslaeger m, chasse e, penninckx f. long-term results after excision haemorrhoidectomy versus stapled haemorrhoidopexy for prolapsing haemorrhoids; a belgian prospective randomized trial. acta chir belg. 2005;105(1):44-52. 19. barron j. office ligation treatment of hemorrhoids. dis colon rectum. 1963;6:109. 20. diana g, guercio g, cudia b, ricotta c. internal sphincterotomy reduces postoperative pain after milligan morgan haemorrhoidectomy. bmc surg. 2009;9:16. 21. mortensen pe, olsen j, pedersen ik, christiansen j. a randomized study on hemorrhoidectomy combined with anal dilatation. dis colon rectum. 1987;30(10):755-757. 22. blaisdell pc. office ligation of internal hemorrhoids. am j surg. 1958;96(3):401-404. 23. macrae hm, mcleod rs. comparison of hemorrhoidal treatment modalities. a meta-analysis. dis colon rectum. 1995;38(7):687-694. 24. felice g, privitera a, ellul e, klaumann m. dopplerguided hemorrhoidal artery ligation: an alternative to hemorrhoidectomy. dis colon rectum. 2005;48(11):20902093. 25. forlini a, manzelli a, quaresima s, forlini m. long-term result after rubber band ligation for haemorrhoids. int j colorectal dis. 2009;24(9):1007-1010. 26. johanson jf, rimm a. optimal nonsurgical treatment of hemorrhoids: a comparative analysis of infrared coagulation, rubber band ligation, and injection sclerotherapy. am j gastroenterol. 1992;87(11):16001606. 27. longo a. treatment of hemorrhoids disease by reduction of mucosa and hemorrhoidal prolapse with a circular suturing device: a new procedure. 6th world congress of endoscopic surgery, pts 1 and 2. 1998:777. 28. madiba te, esterhuizen tm, thomson sr. procedure for prolapsed haemorrhoids versus excisional haemorrhoidectomy--a systematic review and metaanalysis. s afr med j. 2009;99(1):43-53. 29. martinsons a, narbuts z, brunenieks i, pavars m, lebedkovs s, gardovskis j. a comparison of quality of life and postoperative results from combined pph and conventional haemorrhoidectomy in different cases of haemorrhoidal disease. colorectal dis. 2007;9(5):423-429. 30. laughlan k, jayne dg, jackson d, rupprecht f, ribaric g. stapled haemorrhoidopexy compared to milliganmorgan and ferguson haemorrhoidectomy: a systematic review. int j colorectal dis. 2009;24(3):335-344. 31. shao wj, li gc, zhang zh, yang bl, sun gd, chen yq. systematic review and meta-analysis of randomized controlled trials comparing stapled haemorrhoidopexy with conventional haemorrhoidectomy. br j surg. 2008;95(2): 147-160. 32. nisar pj, acheson ag, neal kr, scholefield jh. stapled hemorrhoidopexy compared with conventional hemorrhoidectomy: systematic review of randomized, controlled trials. dis colon rectum. 2004;47(11):18371845. 33. pavlidis t, papaziogas b, souparis a, patsas a, koutelidakis i, papaziogas t. modern stapled longo procedure vs. conventional milligan-morgan hemorrhoidectomy: a randomized controlled trial. int j colorectal dis. 2002;17(1):50-53. 34. correa-rovelo jm, tellez o, obregon l, miranda-gomez a, moran s. stapled rectal mucosectomy vs. closed hemorrhoidectomy: a randomized, clinical trial. dis colon rectum. 2002;45(10):1367-1374; discussion 74-75. keval patel et al. july december 2019; vol. 1, no. 2 j aziz fatm med den clg 76 author’s contribution: dr. keval patel searched material from data bases, literature review and writing of initial draft of manuscript and approving final version. dr. samuel stefan literature review, writing manuscript and approving final version. dr. syed naqvi literature review writing manuscript and approving final version. dr. jim s. khan main concept of manuscript, helped in manuscript drafting, revised all intellectual content. accountable for providing information. 35. mehigan bj, monson jr, hartley je. stapling procedure for haemorrhoids versus milligan-morgan haemorrhoidectomy: randomised controlled trial. lancet. 2000 4;355(9206):782-785. 36. senagore aj, singer m, abcarian h, fleshman j, corman m, wexner s, et al. a prospective, randomized, controlled multicenter trial comparing stapled hemorrhoidopexy and ferguson hemorrhoidectomy: perioperative and oneyear results. diseases of the colon &amp; rectum. 2004;47(11):1824-1836. 37. basdanis g, papadopoulos vn, michalopoulos a, apostolidis s, harlaftis n. randomized clinical trial of stapled hemorrhoidectomy vs open with ligasure for prolapsed piles. surg endosc. 2005;19(2):235-239. 38. sun wm, peck rj, shorthouse aj, read nw. haemorrhoids are associated not with hypertrophy of the internal anal sphincter, but with hypertension of the anal cushions. british journal of surgery. 1992;79(6):592-594. 39. giordano p, overton j, madeddu f, zaman s, gravante g. transanal hemorrhoidal dearterialization: a systematic review. dis colon rectum. 2009;52(9):1665-1671. 40. morinaga k, hasuda k, ikeda t. a novel therapy for internal hemorrhoids: ligation of the hemorrhoidal artery with a newly devised instrument (moricorn) in conjunction with a doppler flowmeter. am j gastroenterol. 1995;90(4):610-613. 41. thomson wh. the nature of haemorrhoids. br j surg. 1975;62(7):542-552. 42. dal monte pp, tagariello c, sarago m, giordano p, shafi a, cudazzo e, et al. transanal haemorrhoidal dearterialisation: nonexcisional surgery for the treatment of haemorrhoidal disease. tech coloproctol. 2007;11(4):333338; discussion 8-9. 43. theodoropoulos ge, sevrisarianos n, papaconstantinou j, panoussopoulos sg, dardamanis d, stamopoulos p, et al. doppler-guided haemorrhoidal artery ligation, rectoanal repair, sutured haemorrhoidopexy and minimal mucocutaneous excision for grades iii–iv haemorrhoids: a multicenter prospective study of safety and efficacy. colorectal disease. 2010;12(2):125-134. 44. scheyer m, antonietti e, rollinger g, mall h, arnold s. doppler-guided hemorrhoidal artery ligation. am j surg. 2006;191(1):89-93. 45. festen s, van hoogstraten m, van geloven a, gerhards m. treatment of grade iii and iv haemorrhoidal disease with pph or thd. a randomized trial on postoperative complications and short-term results. international journal of colorectal disease. 2009;24(12):1401-1405. 46. teo j-y, kam m-h, eu k-w. letter to the editor on the article “treatment of grade iii and iv haemorrhoidal disease with pph or thd. a randomized trial on postoperative complications and short-term results”. international journal of colorectal disease. 2010;25(11):1385. 47. altomare d, infantino a, bottini c, gentile m, buonanno m, hoch j, et al. prospective randomized multicenter study comparing stapler hemorrhoidopexy (sh) with doppler-guided transanal hemorrhoid dearterialization (thd) for iii-degree hemorrhoids. diseases of the colon & rectum. 2010;53(4):580. 48. steinberg dm, liegois h, alexander-williams j. long term review of the results of rubber band ligation of haemorrhoids. br j surg. 1975;62(2):144-146. 49. marshman d, huber pj, jr., timmerman w, simonton ct, odom fc, kaplan er. hemorrhoidal ligation. a review of efficacy. dis colon rectum. 1989;32(5):369-371. surgical management of haemorrhoids j aziz fatm med den college january – june 2021; vol. 3, no. 1 3 original article role of oral iron supplementation in reducing breath-holding attacks in children under five years sadida amir, shakil ahmad, muhammad usman, imran sarwar nisar khan sajid, tanveer ahmad abstract objective: to evaluate the effect of oral iron supplementation in the reduction of severity and frequency of breathholding spells in children under five years. methodology: this observational follow up study included 50 patients aged 6 to 60 months with breath-holding attacks (bhas) and concomitant iron deficiency anemia. it was conducted in the outpatient department of pediatrics in collaboration with the department of pathology at independent medical college, fsd, from december 2012 to march 2013 after taking ethical approval. demographic, clinical and laboratory features were recorded and analyzed. the type, frequency, and severity of breath-holding attacks were recorded on the basis of history. all patients prescribed oral elemental iron at 6mg/kg/day in two divided dosages for 12 weeks were followed every 4 weeks. on completion of 12-weeks of iron therapy, patients were assessed for reduction or remission in frequency and severity of breath-holding attacks. results: the majority of children with bhas (74%) presented during the first 18 months of life. age of onset of bhas was predominant in the 06 to 11 months age group (50%). male children had a higher percentage of bhas (74%) than females. the frequency of bhas per week was up to 10 episodes in most children (76%). the cyanotic subtype of bha was seen in 96% of cases with 66% being severe bhas. moderately severe iron deficiency anemia was a predominant finding (70%). the majority of children (95.65%) reported no adverse events with iron supplementation. 91.30% of children showed a complete response with no attacks while 8.69% showed a good response. there was a complete resolution of severe bhas with only 8.69% remaining in the not-severe bhas category. conclusion: frequency and severity of breath-holding attacks in iron deficient children are effectively reduced after treatment with oral iron supplements keywords: breath-holding spell, children, iron deficiency anemia, iron therapy. introduction breath-holding attacks (bhas) are episodes of ___________________________________________ dr. sadida amir mbbs, fcps professor independent medical college fsd dr. shakil ahmad mbbs, fcps professor aziz fatimah medical college fsd dr. muhammad usman mbbs, fcps associate professor aziz fatimah medical college fsd dr. imran sarwar mbbs, fcps associate professor independent medical college fsd dr. nisar khan sajid mbbs, fcps associate professor aziz fatimah medical college fsd dr. tanveer ahmad mbbs, fcps senior registrar aziz fatimah medical college fsd correspondence: dr. sadida amir email: sadida.72@hotmail.com paroxysmal attacks of involuntary holding of breathing spells followed by loss of consciousness, opisthotonos posture and seizures, that recover spontaneously.1 usually, these spells are triggered by fear, anger, minor trauma, painful and emotionally disturbing events.2 bha is a benign, nonepileptic paroxysmal disorder of infancy and early childhood affecting 0.14.6% of healthy children.1,3 its diagnosis is based on the stereotyped sequence of clinical events that begin in response to provoking factors such as frustration and anger followed by the short period of crying vigorously, end-expiration apnea, cyanosis or pallor and opisthotonic rigidity.4 severe attacks might progress to flaccidity or convulsive movements and loss of consciousness.2 cyanotic and pallid are the two common clinical forms of bha. however, some researcher also described the mixed form that was rarely found in children.2,4 breathing holding spells are manifested because of acute cerebral hypoxia. it is found in children age ranging from 6 months to 6 years mailto:sadida.72@hotmail.com j aziz fatm med den college january – june 2021; vol. 3, no. 1 4 and 76% of these occurs from 6 to 18 months of the age.2,5 treatment options available for bhas include parental counseling about its benign nature and spontaneous resolution with age and medications along with behavioral management.5 it has been suggested that dysfunctional autonomic nervous system, inheritance, asystole due to enhanced vagal tone and iron-deficiency anemia (ida) are contributing factors for the development of breath-holding spells.1,2it is estimated that almost 50% of children under five years of age in developing countries were iron deficient.6 strong evidences are available showing iron deficiency anemia attributed to approximately 23% of cases of bhas. iron has a crucial role in catecholamine metabolism and functions as a cofactor for various enzymes and neurotransmitters of central nervous system (cns). hence iron deficiency results in dysregulation of cerebral neurotransmission causing breath-holding attacks regardless of its type.2 furthermore, the lower hemoglobin adversely effects on uptake of oxygen from the lung and results in anemic hypoxia affecting central nervous system leading to cerebral anoxia.7children with iron deficiency become more irritable and easily provoked to bhas.8 despite being benign and self-resolving it remains frightening and stressful for the parents of the affected children causing depression in them. several researchers have observed a reduction in the severity of an episodic attack of breath-holding with oral iron therapy. there is a paucity of data from pakistan concerning this issue that affect the quality of life of these patients as well as their family.9 we designed this study to evaluate the effect of oral iron supplementation in the reduction of severity and frequency of breathholding spells in children under five years as this age group is more prevalent for bhas associated with iron deficiency anemia. methodology this observational follow up study was conducted by the department of pediatrics in collaboration with the department of pathology at the outpatient department of independent university hospital which is a teaching hospital attached with independent medical college, faisalabad. the study period was 4 months, from december 2012 to march 2013. fifty children between the age group of 06 months to 60 months i.e 05 years with breath-holding attacks of both types (cyanotic or pallid) and concomitant iron deficiency were included in the study. diagnosis of a breath-holding attack and its subtype (cyanotic or pallid) was made on clinical grounds by taking history of bhas from the parents bhas was defined by the following clinical sequence: provocation followed by crying to a point of noiselessness and accompanying change of color (cyanotic), alteration in body tone (pallid) and ultimately loss of consciousness. those bhas resulting in loss of consciousness or convulsions or both were categorized as severe breath-holding attacks. the electroencephalogram (eeg) and electrocardiogram (ecg) were performed to rule out the differential diagnosis of bha (epilepsy and prolonged qt interval) were conducted in each case. diagnosis and severity categorization of iron deficiency anemia as mild (hb 8-12gm/dl, mcv 60-75fl) moderate (hb 58gm/dl, mcv 50-59fl) and severe (hb <5gm/dl, mcv <50fl) were made using laboratory measurements of hemoglobin levels (hb, gm/dl), mean corpuscular volume (mcv,fl) and peripheral blood smear (pbs, microcytic hypochromic). other laboratory tests for confirmation of iron deficiency included serum iron, serum ferritin, and total iron-binding capacity. children with epilepsy or family history of epilepsy, neurologic deficits, febrile convulsions, congenital or acquired cardiopulmonary disease, children already on iron therapy, severe iron deficiency anemia requiring blood transfusion, severe malnutrition, and children with other causes of microcytic hypochromic anemia were excluded from the study. approval of the research protocol was obtained from the independent medical college and university hospital ethical committee (eth/177/144).written informed consent was obtained from at least one parent or caregiver in each case enrolled in the study. a structured proforma was used to record observations of the study. age and sex of the child and age of onset, frequency (number of episodes per week), severity and subtype of breath-holding attack, and severity of the iron deficiency, were recorded in each case on enrolment in the study before starting oral iron supplementation. iron (ferrous sulphate) in a dose of 06mg/kg/day in two divided dosages was supplemented for 12 weeks. follow-up visits were advised at 04 weeks, 08 weeks, and 12 weeks of iron supplementation. each child was evaluated on follow-up for any change in frequency and severity of bhas. the frequency of attacks was based on the number of episodes during that period that had been reported by the mother or any other family member taking care of the child. children were also evaluate for iron deficiency anemia and for adverse effects of oral iron therapy on the basis of laboratory parameters such as complete blood picture and peripheral blood smear showing picture of iron deficiency anemia. reduction in the frequency and severity of bhas were taken as the primary outcome sadida amir et al. j aziz fatm med den college january – june 2021; vol. 3, no. 1 5 variables. according to the data obtained on the reduction of frequency and severity of bhas, patients were categorized into 04 groups: 01complete response (no attack) 02good response (>50% reduction in attacks) 03poor response (10-50% reduction in attacks) and 04no response. statistical analysis: data were analyzed by using spss -19 software. student t-test was used for quantitative data and chi-square test was used for qualitative data. a p-value ≤0.05 was considered statistically significant. results a total of 50 children between the age group of 6 months to 60 months i.e. 05 years with breath-holding (table 1). attacks (bhas) and concomitant iron deficiency anemia (ida) were included in the study. their demographic and clinical characteristics are tabulated in table 01. majority of children with bhas (74%) presented during the first 18 months of life. age table 1: demographic & clinical characteristics (n=50) characteristics frequency (%) age of presentation (months) 06-11 12(24) 12-17 25(50) 18-23 08(16) 24-29 02(4) 30-35 02(4) age at onset of bhas (months) 0-05 02(4) 06-11 25(50) 12-17 12(24) 18-23 08(16) 2429 02(4) 30-35 01(2) 36-60 00(0) sex male 37(74) female 13(26) frequency (number of episodes per week) <05 23(46) 06–10 20(40) 11–15 06(12) >15 01(2) severity of bha severity of bha severe 33(66) not severe 17(34) subtype of bha subtype of bha cyanotic 48(96) pallid 02(4) . age of onset of bhas was predominant in the 06 to 11 months age group (50%). comparatively male children had a higher percentage of bhas than females (74% versus 26%). the frequency of bhas per week was up to 10 episodes in most children. a cyanotic subtype of bha was seen in 96% of cases with 66% being severe bhas laboratory parameters of iron deficiency anemia before and 12 weeks after oral iron supplementation are presented in table 02. as all children included in this study were confirmed iron deficient, microcytic hypochromic blood picture on peripheral blood smear was seen in all cases. moderately severe iron deficiency anemia was a predominant finding (70%). after 12 weeks of iron supplementation, while 34.7% had mild anemia. table 2: laboratory parameters of iron deficiency anemia before and after oral iron supplementation parameter before iron supplementation after iron supplementation (n (%), n = 50) (n (%), n = 46) at 12 weeks severity of anemia mild 09(18) 16(34.7) moderate 35(70) 02(4.3) severe 06(12) 00(0) peripheral blood smear microcytic hypochromic 50(100) 18(39.1) normocytic normochromic 00(0) 28(60.8) p-value ≤0.05 was considered statistically significant during follow-up visits, 4 children were dropped from the study as they stopped reporting for follow-up visits. so 46 children (n-46) complied with the study protocol by the end of 12 weeks of oral iron supplementation. the majority of children (95.65) reported no adverse events with iron supplementation. only 2 children (4.34%) reported loose stools needing iron dosage changes. table 3 shows the response to 12 table 3: response (reduction in frequency and severity of bhas) to oral iron therapy completion at 12 weeks variable n(%) n=46 response p-value number of bhas no attacks 42(91.30) complete 0.00* 1-9 04(8.69) good 0.02* ≥10 00(0) poor or no response 0.00* severity of bha severe 00(0) complete 0.000* not severe good 0.022 adverse effects of iron presented with adverse effects 02(4.34) 0.002* without adverse effects 44(95.65) p-value ≤0.05 was considered statistically significant role of iron in bha j aziz fatm med den college january – june 2021; vol. 3, no. 1 6 week oral iron supplementation therapy in terms of reduction in frequency and severity of bhas. 91.30% of children showed a complete response with no attacks by the end of 12-week iron therapy while 8.69% showed a good response. there was a complete resolution of severe bhas (severity) with only 8.69% remaining in the not-severe bhas category (table 3). discussion this study was conducted to highlight the importance of oral iron therapy on reducing the frequency and severity of bhas in the iron deficient children with cyanotic and pallid breathing holding spell. as there is high prevalence of iron deficiency anemia and associated bhas in our population, we aimed to observe the outcome of oral iron supplements in patients of breath hold spell among the children of under five-year age.10 current results shows that 74% of the children presented with bhas during the first 18 months of life. of total subjects, 50 % of the children being affected with bha were in age groups from 06 to 11 months. our these results are in accordance with lal et al study conducted at larkana pakistan showing majority of the cases were presented from 9-12 months which are almost of same age groups to our results.5 least age presentation with bha age in our study was 36-60 moths i.e 3 to 5 years and this clicnical presentaion in terms of age is in accordance to the previous study doumenting that 90% of children the spells got remission by school age and the persistence is extremely rare beyond 4 years.3,11 in present study bhas attacks were most frequently found in male children as compared to females (74% versus 26%). congruent findings were reported by previous studies conducted at pakistan and iran showing the male predominance in term of bhas.7,11,12 present results reveals, frequency of bhas per week was up to 10 episodes in most children. a cyanotic subtype of bha was seen in 96% of cases with 66% being severe bhas. these results are in line with the previous study carried out by lal et al, reporting majority of the subject presented with cyanotic spells.5current results are also in agreement with the study conducted by khan et al that reported 79.1% of participant were presented with cyanotic spell, reflecting predominance of cyanotic bhas.12 current results shows70%,18% and 12% of the participants presented with moderate, mild and severe anemias respectively. after oral iron supplementation for 12-week in terms of reduction in frequency and severity of bhas, we found 91.30% of children showing a complete response with no attacks while 8.69% showed a good response. these results are supported by the jain et al showing that improving anemia with iron is helpful for managing bha.13 congruent results are reported by kahn et al reporting statistically significant fall in the frequency and severity of bhas with 12 weeks of iron treatment.12 a study by bidabadi et al reporting that 76.19% of the study participants showed complete control of bha, after iron therapy.14 these findings are in accordance with the results of our study. some previous studies have suggested that it is self-resolving condition and remission usually occur before school going age , but the attitude problems in the parents and the child may trigger spells and with proper psychotherapy consultation with the parents, these spells may be prevented to a large extent.15 limitations: small sample size and absence of control were the limitation of the study. results were not generalized to whole population. current results might still be widely applicable as they are similar to results reported by previous international studies and will help in establishing patient-specific treatment. conclusion frequency and severity of breath-holding attacks in iron deficient children are effectively reduced after treatment with oral iron supplements. recommendations: to validate these results, future researches on wider scale for more duration follow-up, optimal dose and length of treatment should be considered to evaluate long-term benefits and serious side effects of iron supplements in the prevention of severe bhas funding source: none. conflicts of interest: none. references 1. leung akc, leung aam, wong ahc, hon kl breath-holding spells in pediatrics: a narrative review of the current evidence. curr pediatrrev.2019;15(1):2229.doi:10.2174/1573396314666181113094 04. 2. gürbüz g, perk p. iron supplementation should be given in breath holding spells regardless of anemia. tuyrk j med sci. 2019 ;49 (1) 230-237. doi: 10.3906/sag-1805-92. 3. goldman r d. breath-holding spells in infants. can fam physician. 2015;61(2); 149-150. 4. azab sfa, siam ag, saleh sh, elshafei mm, elsaeed wf, arafa ma, et al. novel findings in breath-holding spells: a cross-sectional study. med (united states). 2015;;94(28):e1150. doi: 10.1097/ md. 0000000000001150. 5. lal s, lal s, siddiqui ai, jamro b, jamro s. breath-holding spells mimic seizures, its clinical features and outcome. med channel. 2014; 20(1):30-34. sadida amir et al. https://pubmed.ncbi.nlm.nih.gov/30421679/ https://pubmed.ncbi.nlm.nih.gov/30421679/ j aziz fatm med den college january – june 2021; vol. 3, no. 1 7 6. parbey pa, tarkang e, manu e, amu h, ayanore ma, aku fy, et al. risk factors of anaemia among children under five years in the hohoe municipality, ghana: a case control study. anemia. 2019; 2019:2139717. doi: 10.1155/2019/2139717. ecollection 7. ziaullah k, nawaz s, shah s, talaat a. iron deficiency anemia as a cause of breath holding spells. journal of postgraduate medical institute 2005;19(2):171‐174. 8. pasricha sr, tye-din j, muckenthaler mu, swinkels dw. iron deficiency. the lancet. 2021. 16;397(10270):233-248. doi: 10.1016/s0140-6736(20)32594-0. 9. zehetner a, iron supplementation reduces the frequency and severity of breath holding attackd in non anaemic children. clinpract. 2011;1 (4);e98availablefrom:https://www.ncbi.nlm.nih.gov/pm/articles/pmc 3981420/[cited :june 20, 2020] 10. shamoon m, shaukat s, bajwa fe, ahsan m. iron deficiency anemia in pediatric patients with breath-holding spells. apmc 2018; 12 (4) :256-259. 11. abbaskhanian a, ehteshami s, sajjadi s, rezai ms. effects of piracetam on pediatric breathholding spells: a randomized double blind controlled trial. iran j child neurol autumn2012; 6(4):9-1. 12. khan i, muhammad t, khan ma. effectiveness of oral iron supplement on breath-holding spells in children. jmed sci.2012;20(3): 138-141, 13. jain r, omanakuttan d, singh a, jajoo m. effect of iron supplementation in children with breath-holding spells. j. paediatr. child health. 2017;53(8):749–753. 14. bidabadi e, poornabi darzi s, mashouf p shahraki t. effectiveness of iron therapy on breath-holding spells in the children iran j child neurol. autumn 2019; 13(4): 155-161. 15. hüdaoglu o, dirik e, yiş u, et al. parental attitude of mothers, iron deficiency anemia, and breath-holding spells. pediatr neurol. 2006 ;35(1):18–20. authors’ contribution: dr. sadida amir study design, acquisition of data and manuscript write up. reviewed and approved the manuscript. dr. shakil ahmad study design, data collection, critically revised all the content, reviewed and approved the manuscript. dr. muhammad usman study design perform lab test, and provide lab reports for data analysis, compiling and analysis of data, interpretation of results, revise manuscript and approved it. dr. imran sarwar data collection, data analysis write up and revising manuscript critically for study design important intellectual content and approved the manuscript dr. nisar khan sajid data analysis and interpretation of results, manuscript writing and approved the manuscript. dr. tanveer ahmad study design, help in data analysis , critically revise and approved the manuscript all authors are responsible for research work , data integrity of the data and the accuracy of the data analysis role of iron in bha received: 15 nov 2020, revised received: 05 jan 2021, accepted: 07 jan 2021 https://www.ncbi.nlm.nih.gov/pm/articles/pmc3981420/ https://www.ncbi.nlm.nih.gov/pm/articles/pmc3981420/ j aziz fatm med den college july december 2020; vol. 2, no. 2 62 proceeding proceeding of certificate course in medical editing at university of health sciences lahore shireen jawed lahore: university of health sciences (uhs) in collaboration with pakistan association of medical editors (pame) has initiated a certificate course in medical editing with an objective to help build professional capacity of editors of biomedical journals. this six-month course with two contact sessions of four day each will also enable other healthcare professionals who wish to take up medical journalism as a career or wish to have an additional qualification being interested in scientific publishing. mr. shaukat ali jawaid chief editor, pakistan journal of medical sciences (pjms) who is also secretary of eastern mediterranean association of the medical editors (emame) is the course coordinators while over a dozen other distinguished editors from pakistan, saudi arabia and islamic republic of iran are also affiliated with this course as facilitators and mentors.1 in fact this is the first module which will be followed by an advance course in medical editing module two, then module three and finally module four which will eventually lead to a master’s degree. all the modules are of six months duration and they include assignment portfolio, final assessment and viva exam while module correspondence dr. shireen jawed email: drshireenjawed@gmail.com four will consist of a thesis. first contact session first contact session for the first batch was organized from 4th september 2018 to 7th september 2019. facilitators in this session included mr. shaukat ali jawaid, chief editor of pakistan journal of medical sciences, prof. jamshed akhtar editor of journal of the college of physicians and surgeons pakistan (jcpsp) and dr masood jawaid (associate editor pjms). on the first day mr. shaukat ali jawaid gave a brief introduction of cme course and pointed out its importance and commended the efforts of pame and uhs for this good initiative for capacity building of editors that could be helpful in uplifting the standards of biomedical journals published from pakistan. he discussed at length basic principle of medical writing, essential component of an original article which included structure abstract, introduction, methodology, results, discussion and conclusion. he also highlighted the importance of internal review and copy editing. he shared useful tips for initial screening also known as editorial triage, internal review and medial editing. he stated that look carefully at the title and objectives of manuscript. make sure that they match each other. during initial screening or internal review one should participants, of the certificate course in medical editing (first batch) at uhs photographed with vc uhs prof. javed akram,,course coordinator mr. shaukat ali jawaid , president pame prof. jamshed akhtar and members of the organizing committee. j aziz fatm med den college july december 2020; vol. 2, no. 2 63 check the manuscript for essential component of an article. ensure that the structured abstract is in four headings like objective, methodology, results, conclusions and appropriate mesh key words. some authors also use background instead of objective but it is better to shift information of background into introduction if not essential, he suggested. a new sentence should not start with figure but write it in words particularly the single digit figures to avoid mixing it with references which should always be in superscript. follow icjme guidelines while writing the references by listing up to six authors followed by et al. make sure that the journal with which you are affiliated, there is uniformity in abstract, references and page numbering in references. the references should be in order i.e. 1,2,3,4 and so on. any reference can be repeated but make sure that the reference in the text also tally with the reference list at the end. some authors while revising the manuscript when use endnote for references, it does create some problem and references are changed. hence it is always better to check each and every reference in the text that it tally with the reference list manually before final submission. reference to local studies are a must and make sure that atleast 3050% of the references are from the last five years which will increase the chances of acceptance of manuscript for publication. it is essential that the relevant information is included in the appropriate section i.e. introduction, methodology, results, discussion. discussion is the most important part which should have most of the references as it is here where the authors are supposed to compare their results with other studies locally to national, regional and international studies. it is only possible with proper literature search. as per icmje guidelines, summary of review articles must include the time period and the databases searched and number of articles selected for review. one of the reasons for rejection of manuscripts he stated was inclusion of information in inappropriate section i.e. something which should have come in introduction is included in methodology and so on. yet another mistake committed by authors and some editors as well was not making differentiation between patients and methods and material and methods. to avoid all this confusion, it is better that one uses the word methods or methodology in abstract as well as text which will cover the studies irrespective of the fact whether it included the patients, healthy subjects of material. he laid emphasis that one should convey the message effectively using simple language and small sentences. ensure that all tables and figures are described in result, they have proper foot notes, headings and must convey the message in standalone position and readers do not need to read the text. later in this session authorship guidelines by icmje were also discussed. roles and responsibilities of medical editors were emphasized along with following professional ethics and ensuring that only those are listed as authors who are eligible and the menace of gift authorship is discouraged. he also spoke about editorial freedom, decisions power and contract appointment for editors. editors should be, honest and never misuse their position. he further pointed out that availability of minimum staff was a pre-requisite for successful publications of journals. he made it clear that editorship is full time stressful job, and it needs a team work. transparent policy regarding processing fee, publication charges, peer review system how the journal handles scientific misconduct are extremely important and all this information must be included on the journal website which will help the journal in indexation with reputed data bases. authentication of declaration of publisher and printer from the government of pakistan which is issued by the district magistrate after issuance of no objection certificate by the press information department (pid) of ministry of information broadcasting pakistan was the most important and prerequisite for starting a journal. second day was devoted to discussion on provision of constructive unbiased peer review and maintaining quality of publication. this session was facilitated by prof. jamshed akhtar. he emphasized the importance of an effective peer review system while the editors are supposed to review the reviewer’s comments before they are forwarded to the authors for revising their manuscripts. peer reviewer should be subject expert with strong research back ground. many journals have inexperienced editorial board and lack experienced reviewers. he further stated that quality of the manuscripts published by many inexperienced editors are also questionable. some journals face paucity of manuscripts. bypassing the editorial process and publication of article without peer review should be discouraged, he remarked. he discussed different types of peer review system and said that hec lays emphasis on double blind peer review system. further he discussed advantages and disadvantages of open and double blind peer reviews systems. the peer review policy adopted by the journal must be clearly mentioned on journal website. reviewers should be provided guidelines in the form of a proforma which should be open ended. reviewer’s comments should help the author to improve their shireen jawed j aziz fatm med den college july december 2020; vol. 2, no. 2 64 manuscripts. if the reviewers have some conflict of interest, they should inform the editor and refuse to review the manuscripts. if the reviewer needs some more time, this should also be communicated to the editor. in case of conflict of interest reviewers should inform to editors and refuse to review article. he also emphasized on timely review. dr jamshed akhtar further pointed out that he has seen some papers in clinical sciences such as pediatrics or surgery where in some of the authors are listed from department of basic sciences who have nothing to do with them. such unethical practices need to be checked. there was lot of debate on this issue of authorship and at the end it was agreed that now basic sciences are being integrated with clinical sciences from the very beginning hence there is no harm with such authorship but authorship guidelines by icmje should be followed. those who have intellectual, meaningful contribution only those are eligible to be listed as authors. later on mr. shaukat ali jawaid discussed different business models for long term sustainability of the medical journals. on the third day mr. shaukat ali jawaid shared his experiences. we as editors, he stated, should encourage and guide authors rather than discourage them. one of the common causes of desk rejection of papers is not following the instruction for authors published by journals, he added. this was followed by the presentation by dr masood jawaid, who highlighted the importance of digital object identifier (doi) and networking. this system provides a technical and social infrastructure for the registration and use of dois, for use on digital networks, he stated. it is the url number and object/article identifier. its important feature is to redirect the objects/articles through handle system. doi was introduced by international doi foundation (idf) which is iso certified, he added. he further stated that crossref is one of the important regulatory agencies which provide this digital identifier number. further he added that extensibility, independence, dynamic updating, multiple resolution, interoperability and class management are the advantages of doi. the fourth day of session was facilitated by mr. shaukat ali jawaid and dr. masood jawaid. mr. shaukat ali jawaid summarized discussions of previous three days. he stressed on initial screening, internal review, importance of external peer review and eligible authorship. he gave his view about editorship and emphasized on editorial independence of editors. major part of this session was devoted to open journal system (ojs). he also highlighted various pressures on editors and said that authors were the most dangerous pressure group which the editors have to face as they wish to get their manuscripts published immediately after submission.2 most often the authors demand that they should be provided an acceptance letter while the paper can be published later but little do they realize that an acceptance letter can be issued only once the manuscript has gone through the whole peer review process which takes time and there is no short cut. some authors wish their manuscripts to be processed on fast track for which they are prepared to pay extra fee but even this facility provided by some journals is not available all the time. while doing post acceptance editing, one might come across some deficiencies which have to be rectified. sale and purchase of the authorship and gift authorship is quite common which are a challenge for the editors. to avoid the possibility of any error in published article, pdf file should be sent to the authors prior to publication for proof reading. some authors do not know how to make corrections, instead of making corrections in pdf files they make correction in their original submitted files which creates more problems for editors. moreover, some journals publish the corrected final manuscript ahead of print on the journal website which provides another opportunity to the authors to see if all the corrections they had marked have been carried out and if not, they can point it out and get it corrected. incomplete submissions and lack of required documents including ethical approval and signed undertaking form by all the listed authors is yet another common reason for desk rejection, he stated. during discussion the issue regarding publication of manuscripts by the editors in their own journals was also raised. some participants pointed out that some regulatory bodies require that, editors should not publish his/her own article in their journals. mr. shaukat ali jawed remarked that there was no harm in publishing in one’s own journal but it must go through the proper peer review system. dr. masood jawaid demonstrated all aspects of the open journal management system (ojs). he demonstrated about the setting for journal, sending submitted article for review and communication with authors by ojs. ojs offers many advantages, he stated. he emphasized to use journal management system for transparent processing of submitted articles to medical journals. all participants also had hands on practice on ojs at the end of the session under supervision dr masood jawaid. second contact session the second contact session also comprised of four proceeding cme at uhs j aziz fatm med den college july december 2020; vol. 2, no. 2 65 days from 11th december to 14th december 2019. first day session was facilitated by mr.shaukat ali jawaid. in his informal talk he emphasized the importance of spreading, sharing knowledge. he quoted late major gen. mohsin pal former director general of health who while speaking at the formal launching ceremony of book on medical writing authored by mr. shaukat ali jawaid had remarked that “knowledge flows to those who are capable of receiving it, respecting it, protecting it, preserving it and promoting it.” he gave feedback about assignments of cme candidates and guided them about the contents of their portfolio. an interesting part of that session was the discussion concerning the reporting of adverse drug reactions (adr). he highlighted the importance of reporting adr and described the facts responsible for not reporting and publishing adverse reaction in pakistan. he said that many of the pakistani medical journals are dependent on advertising from the pharma trade and industry hence; most of them do not want to highlight or publish the adverse reaction of their drugs, which could affect their sales. on the other hand, in some clinical trials they wished to publish only favorable results of these trials. another possible cause of failure of reporting adr is ignorance by doctors, he opined. many juniors doctors lack clinical skills and do not monitor adverse reaction. some senior doctors are also not reporting the adr due to their ignorance or cordial relations with pharmaceutical companies and don’t want to lose benefits/ privilege they enjoy. he further described the role of editors in publishing adr. he suggested publishing adr after peer review; one can also ask the pharmaceutical company concerned to provide if they have any post marketing surveillance reports related to those drugs. professional ethics demand that company’s view point should also be published along with the response from the author. adr is important for patient’s safety and care. he advised editors to understand their duty concerning reporting adr, publish it after ensuring transparency, clinical relevance and credibility of report. the important three functions of the press, he further stated, are to inform, educate and guide. all these require different level of professional expertise. he stressed that there are some well-known professional competencies for the editors.3 journalist/editors must keep their knowledge updated, as the ignorant journalists could be harming the society by spreading the wrong information. in last part of the session, he discussed the role of medical editors in improving the patient care through research. he highlighted the functions of medical editors and emphasized to update their knowledge as their role is not only accepting or rejecting the article but they have to teach and guide the authors. editors have pivotal role in highlighting public health problems and improving patient’s safety. they have role in promoting the ethical practices in health sectors. he then shared his personal experience how he picked up the idea of working on diabetic foot to improve its care in pakistani patients, wrote an editorial highlighting the plight of diabetic foot patients. this eventually resulted in the establishment of the first diabetic foot clinic at baqai institute of diabetes and endocrinology at baqai medical university (bide) at karachi. later bide under the leadership of prof. abdul basit helped establish numerous diabetic foot clinics all over the country helping improve diabetic foot care in pakistan which also reduced the amputation rate by almost 50%, he added. dr fatema jawad chief editor of journal of pakistan medical association was the facilitator on second day of this contact session. she spoke about publication misconduct and discussed various flow charts prepared by committee on publication ethics of uk (cope) and its guidelines related to problems faced by editor. in next part of her presentation she described the various types of scientific misconducts including falsification, fabrication and plagiarism. types of the plagiarism she mentioned included word to word, mosaic model, paraphrasing without giving the references and image manipulation. she urged the participants to avoid image manipulation as it can also change the results. she further stated that authors must avoid plagiarism because when caught; it leaves a bad impression, not only results in rejection of an article and might be retracted even after publication. she also emphasized the importance of avoiding duplicate submission as well as publications which can be prevented by ensuring that all authors listed on the manuscript have singed the undertaking form. she also suggested avoiding falsification, fabrication, salami slicing and redundant publications etc. she then discussed various case stories related to falsification and fabrication, and their consequences. she also talked on conflict of interest which could be due to personal relationships, honoraria, financial relationship, relationship with industries and academic competitions. she was of the view that it is the moral duty of seniors to educate their juniors for the ethical writing to preserve integrity and accountability of the research. she further added that many authors indulge in scientific misconduct for their promotions and getting degrees but it is unethical and the regulatory bodies can take serious action which could be in the shireen jawed j aziz fatm med den college july december 2020; vol. 2, no. 2 66 form of removal from the job, demotion thereby putting their whole academic career at stake. she suggested that journals should have transparent policies to deal with the publication misconducts and it should be available on journal websites. every journal must have software like ithenticate or turnitin for detecting plagiarism and follow cope guidelines for publication ethics. dr. saira afzal editor of annals of kemu was one of the speakers on the third day of this contact session. she described the success story of the annals of king edward medical university (akemu). she said that for akemu she was lucky to be selected as a recipient of dr. maqbool h. jafary training scholarship started by mr. shaukat ali jawaid in memory of their late founder chief editor. she appreciated his efforts in medical journalism and training of young editors to uplifting the standards of medical journals of pakistan. mr. shaukat ali jawaid always highlighted problems faced by medical journals of pakistan in different forums including regulatory bodies, she remarked. at annals of kemu we practice double blind peer review system she stated. she moreover briefly referred to indexation of journals by various databases like clarivate analytics, medline, pubmed, index medicus, directory of open access journal (doaj), pubmed central and scopus etc. availability of articles on various databases will make it visible and easily searchable which enhance the readership and citations, she added. she also highlighted the importance of a good peer review system for ensuring quality of manuscripts accepted for publication. she suggested to have separate web sites for the journals from the institutional websites and use of open journal system for processing the manuscripts. she further stated that the use of ojs and regular timely publication are mandatory for recognition of journals by regulatory bodies. she emphasized to maintain the archives of previous at least ten years published issues of journals on web site, as it will increases the citation of journals which can be checked through google scholar. she guided editors to get membership of professional associations such as pakistan association of medical editors(pame), world association of medical editors (wame) and eastern mediterranean association of medical editors (emame). she opined that various editorial board members of the journal should write editorials, instead of one person writing editorial for prof. javed akram vice chancellor uhs presenting a memento to dr. fatema jawad editor-in-chief of jpma.mr. shaukat ali jawaid chief editor of pakistan journal of medical sciences and coordinator of the course is in center proceeding cme at uhs shireen jawed j aziz fatm med den college july december 2020; vol. 2, no. 2 67 every issue. she appreciated efforts of it departments of king edward medical university (kemu) which has played a vital role in success of akemu. she introduced the quick response (qr) code generated by it department of kemu, used for tracing citations of akemu. later mr. shaukat ali jawaid, talked about the role of media in spreading the knowledge and how to deal with media personnel. during his talk he pointed out that the media has important role in spreading the correct information and educating the society on various issues including problem related to health. he also expressed his views about the role of science in health and environment and spreading this knowledge by media. media personnel, he emphasized should have core knowledge about the subjects. they must avoid the dissemination of wrong information, which could be harmful for society. he pointed out that in pakistan the owners of media houses seldom hire the journalist with core knowledge and are spreading the incorrect information. he suggested that professional specialty organizations should educate the media personnel. he shared various examples of incorrect reporting by the media and their harmful effects. he said that the media can act as translator and gate keeper to play positive role in spreading correct information. they can simplify scientific knowledge which can also be easily comprehended by lay man. he encouraged developing good relations with media personnel to convey the correct message to society. he also talked about the social media, blog, and twitter. he further opined that the media can play its positive role in spreading the knowledge about the health related problems and common diseases. he explained that various telefilms, dramas and talk shows can easily create awareness about common diseases and important health issues. however, the scientists and medical profession should have communication strategies with media personnel. he laid stress on self-monitoring of medical as well as media professionals to avoid the mishaps and they should play positive role in betterment of society. there is need to fill the communication gap between the medical and media professionals for creating awareness of the community related health problems. last and the fourth day of 2nd contact session was facilitated prof. dr. akhter sherin chief editor khyber medical university journal. he also has an important role and contributions for the enhancement of medical journalism. he discussed authorship criteria laid down by icjme guidelines. this was an excellent debate clearing all concepts regarding authorship. the salient features of the icmje guidelines on authorship, he stated, were:  interpretation of data for the work; and substantial contributions to the conception or design of the work; or the acquisition, analysis, or  drafting the work or revising it critically for important intellectual content; and  final approval of the version to be published; and  agreement to be accountable for all aspects of the work in ensuring that questions related to the accuracy or integrity of any part of the work are appropriately investigated and resolved. he pointed out that many authors are unaware of this guideline causing authorship issues. he discussed the differences between the authorship and non-author contributors. all those who help in conducting the study but do not fulfill the icmje four criteria to be eligible to be listed as authors should be covered in acknowledgment. he suggested that all those who have helped in the conduct of study should also be acknowledged. supervisors, those who helped only in securing funding, other colleagues who have helped in study design, lab assistants should be acknowledged, he stated. statisticians without significant contributions are not eligible to be listed as authors. supervisor can be included in authorship,if he/she has made significant contribution.5 he stressed that supervisors should not be the 1st author. first author should be the one who has actually done the study or has major contribution in the study. mr.shaukat ali jawaid pointed out that acknowledgment is considered as an endorsement of the study findings that is why now it is being discussed at different forums that authors should be asked to provide written permission from those who are being acknowledged. this is still under discussion and no final decisions have been taken so far, he stated. prof. akhtar sherin then talked about the gifted and ghost authorship. authorship granted to those who are not full filling icjme criteria is gifted authorship. many authors include the names of their seniors in respects or head of their department, institution just to increase the chance of publication comes in the category of gift authorship.4 the author who full fill the criteria of authorship but not included in the authorship list or author hired purely for the purpose of writing but not acknowledged are ghost authorship, he remarked. later on various problems faced by editors concerning authorship were discussed. he also referred to the addition or removal of thr author’s name from article before and after publications which was followed by lively discussion by the participants. in last session, prof. akhtar sherin discussed about systematic review, meta-analysis and narrative review. he pointed out that the systematic review and meta-analysis have j aziz fatm med den college july december 2020; vol. 2, no. 2 68 major role in making guidelines. randomized control trials are also useful for making guidelines. he also referred to the prisma guidelines for meta-analysis. at the end test was taken based on different scenarios. in the end of session mr. shaukat ali jawaid in his concluding remarks appreciated the whole batch of cme. he hoped that all the participants will work hard for the improvement of their journals making use of the information they have got during the course. conclusion throughout the course (first and second contact sessions), participants of cme learned editorial triage, how to edit manuscript, cross checking of references, recognize plagiarism and scientific misconducts. they learned about the different peer review systems. how to communicate with authors, reviewers, and editorial board members was discussed in detail which will be extremely useful for the participants. overall, this course was intellectually satisfying and strengthens critical cognition skills of the participating editors. editors of various journals who participated in this course will be in a better position to critically analyze the submitted manuscripts. they would be able to recognize and take decision about different types of misconduct. this all became possible because of guidance and encouragement of course facilitators and mentors. references 1. certificate in medical editing. http://www.uhs.edu.pk/ cme.php.[cited on: oct 27, 2020]. 2. jawaid sa. problems faced by editors of peer reviewed medical journals. saudi med j. 2004;25, suppl 1.pp 447-451. 3. jawaid sa, jawaid m. professional competencies required for editors of biomedical journals. pak j med sci.2017;33(5):10 50-1052.doi:10.12669/pjms335. 13967 4. jawaid sa, jawaid m. some useful tips to detect gift authorship. pak j med sci. 2020 ; 36 (6) : 1145-1146 doi:https://doi.org/10.1 2669/pjms.36.6.3154 5. international committee of medical journal editors.recomm endations for the conduct, reporting, editing and publication of scholarly work in medical journals. available from: http;/www.icmje.org.[cited on : oct 27,2020] proceeding cme at uhs http://www.uhs.edu.pk/cme.php http://www.uhs.edu.pk/cme.php https://doi.org/10.12669/pjms.335.13967 j aziz fatm med den college january – june 2021; vol. 3, no. 1 8 original article perception of health sciences students about impact of hidden curriculum on burnout and empathy komal atta, saadia ijaz abstract objective: the main objectives of this study were to investigate how the implicit curricular aspects such as the hidden curriculum affect student empathy and burnout and we sought to describe the link between them. methodology: this mixed methods study included validated measures of both empathy and burnout which were distributed in three institutes of three different cities in pakistan followed by focus group interviews. the study cohort included students of health sciences. 2000 questionnaires were distributed of which complete data of 1100 (55%) were retrieved. the second part of the study included formation of two focus groups of 15 students each per campus for in-depth discussion of aspects relating to the hidden curriculum, burnout and empathy. descriptive statistics, correlations and frequencies were analyzed by spss 22 and focus group discussions underwent thematic analysis after transcription. results: medical students followed by and physical therapy students experienced the greatest amount of burnout syndrome (p-value0.02 and p-value0.04, respectively) as compared to the other disciplines final year students of each discipline reported higher rates of burnout as compared to all other years (p-value0.01).medical students had lesser empathy as compared to other disciplines of health sciences. this finding showed statistical significance (f=4.66.p-value0.03). furthermore, results shows females (5.56±0.72) had statistically significant higher empathy scores than male students (4.46±0.65) (p-value 0.04). the focus groups established that the hidden curriculum was a key player in student wellbeing and not just limited to subconscious attributes of the teacher but it also includes administrative issues, patient behavior, peer interaction, sociodemographic and national policy issues. conclusion: medical students experienced the greatest amount of burnout and subsequently reported lesser empathy reflecting the negative relation between them. burnout and hidden curriculum are important factors in determining empathy in health care students. more positive role modeling, better understanding of the surrounding and a good distribution of work load will help the students handle burnout and act as positive factors of the hidden curriculum, hence increasing empathy. keywords: empathy, hidden curriculum, burnout, undergraduate, medical students introduction empathy is a crucial part of any medical and allied health science career, practice or even apprenticeship. it is the one thing which links us directly not by science but by emotions to our patients, hence it is stressed upon in all medical and allied health science disciplines to give an increasing amount of empathy training and exposure to their students.1,2 psychologists now believe that empathy is an amalgam of both acquired skills as well as specific person. many measures of empathy now exist thanks to the vast array of research done now relating to this issue, the jefferson scale-student edition (jse-s) is one of the most widely used questionnaire ____________________________________________________________ dr. komal atta mbbs, mphil assistant professor university medical and dental college, tuf, fsd dr. saadia ijaz mbbs, mphil senior demonstrator shalamar medical and dental college. lhr correspondence: dr. komal atta email: komal.atta@gmail.com to judge student empathy. it has been validated multiple times in various countries of the world. 4,5 on the other hand, burnout can be defined as a constellation of negative and energy draining symptoms in an individual, that consists of syndromic exhaustion physically and also emotionally, decreased personal accomplishment and feelings of depersonalization.6 this is one of the commonest features of medical practice and education owing to the long working hours, grueling study routines, schedules and cut throat competitiveness in the field, as well as external factors such as patient non-cooperation, lack of support among peers etc.7 the maslach burnout inventory is a verified scale exploring causes of burnout in various domains in a person. it has been used in multiple studies worldwide to assess the causes and effects of burnout.8,6 the hidden curriculum refers to the impact made by the social structures, tacit dogmas and other circumstances in the environment other than academic learning which impact a person’s social and professional behavior.9 this is of particular relevance to medical education mailto:komal.atta@gmail.com j aziz fatm med den college january – june 2021; vol. 3, no. 1 9 and health care professionals where students are always passively exposed to tacit learning in activities such as “shadowing”, “mirroring” senior fellows and teachers and are often asked to adopt dehumanizing elements such as “developing thick skin” and becoming “robotic” to survive in a contemporary medical practices.10,11 in pakistan in particular, less emphasis is given to empathy and effects of the hidden curriculum in the medical education.5these areas are highly unexplored as compared to the didactic curriculum and formal methods of teaching. apart from this due to very high patient load in our clinical setups as well as teaching hospitals, students are subjected to greater levels of burnout.12 the objective of our study is to correlate the effects of the hidden curriculum and the rate of burnout on the empathy levels of medical and health sciences students so we may be able to evaluate our setups and teaching styles in order to create a safer, calmer and healthier environment for our students to study and grow into mature, empathetic health care providers. methodology this study was carried out from march 2019 to march 2020. ethical approval was taken from the research and ethical review committee of “the university of faisalabad” with letter#:tuf/dean/2019/14.validated questionnaires were distributed in three different institutes which catered for both medical as well as allied health sciences students. main university where the research was conducted was in faisalabad where as other two universities were lahore and islamabad based. the total population of the three universities combined was about 14907 students. sample size (n=2000) was calculated at 95% confidence interval, with ±2% margin of error, using formula: n=[deff*np(1-p)]/[(d2/z21-α/2*(n-1)+p*(1-p)] where n=sample size, n=population size, p-value hypothesized frequency of outcome in a population d=margin of error, deef= design effect for cluster surveys.13 in the first phase of the study from march 2019 to may 2019, on a sample size of 2000 a small structured questionnaire regarding sociodemographic characteristics including gender, year of study, program of study and the maslach burnout inventory (student edition) and the jefferson empathy scale (student version) were distributed randomly in health science departments at the three institutions. of these, complete data of 1100 forms were retrieved (55%).submission of responses by the students were the willingness of participation in the study and were included in the study. students who did not submitted their proforma were excluded from the study. the maslach burnout inventory is a selfadministered closed format questionnaire with 15 questions subdivided into three scales of emotional exhaustion(5items),cynicism (4 items) and professional efficacy (6 items). scoring is done on a 6-point likert scale; however we use the scale inverted when measuring professional efficacy. the crohn bach alpha for each factor respectively came out to be 0.77 ,0.8 and 084 which was considered good compared to previous studies using the same scale.14–16 as followed from previous literature burnout was identified at higher levels based on the following scoring system: emotional exhaustion>14, cynicism> 6 and professional efficacy >23. the jefferson empathy score, students version is a 20 item questionnaire rated on a 7-point likert scale. it composes of both negative and positive correlations.15 statistical analysis: was carried out on spss version 22.descriptive statistics were applied on all demographic data, the mbi-se items were evaluated using backward linear regression analysis, bivariate analysis to compare various descriptive with individual descriptive components, chi square test was applied to see the impacts of gender, year of study and discipline of study on burnout. jspe scores were reported as mean± standard deviation of each item, the evaluation of empathy with advancing years of study and different disciplines were evaluated using analysis of variance (anova) and independent t-test was employed to find out the difference in empathy between genders. a p value was rendered significant if p≤0.05. in the second phase of the study, two focus groups of 15 students were formed in each specialty at all three institutes by multistage sampling technique. total 90 students were in focused groups these groups were monitored by two mentors each who were not directly involved in teaching that specific cohort of students which they were assigned. various themes that emerged in the discussions were transcribed and repetitive or common elements were considered for the study. results of the 1100 students who responded, the population was predominantly female (59%), more students of first year and final year responded and the highest responding discipline was medical sciences, as shown in table 1. according to the mbi-se, alarming 40% students were falling in the defined criteria of burnout syndrome. separate analysis of each individual items komal atta et al. j aziz fatm med den college january – june 2021; vol. 3, no. 1 10 table 1: descriptive data collected for all students who responded with completed questionnaires (n=1100) variable frequency (n=1100) percentage (%) gender male 450 40.90% female 650 59.09% year of study 1st year 250 22.72% 2nd year 189 17.18% 3rd year 166 15.09% 4th year 245 22.27% 5th year 250 22.72% discipline of study medical sciences (mbbs and bds) 554 49.45% physiotherapy 261 23.72% medical laboratory techniques 85 7.7% optometry 200 18.18% scale showed that a larger part of our sample population had higher means in high cynicism (7.2±5.6 α=0.77), high professional efficacy (28.0±5.7,α=0.81) and high emotional exhaustion (16.8± 5.9,α=0.84) table 2: of gender, year of study and discipline of study on empathy. (n= 1100) source f statistic significance discipline* year of study 0.86 0.01* discipline*gender 0.95 0.49 gender*year of study 0.99 0.54 discipline*year study*of gender 0.89 0.23 pvalue ≤ 0.05 was considered significant the cronbach alpha is used as a determinant of reliability of this study, it verified good internal consistency (α=0.70) the reliability of this study, assessed by cronbach’s alpha, verified that the subscales of emotional exhaustion (0.83), cynicism (0.78) and professional efficacy (0.80) presented good internal consistency(alpha.0.70) the burnout syndrome was more significant in medical science and physical therapy students (p-value 0.02 and p-value 0.04, respectively) as compared to the other disciplines. final year students reported higher rates of burnout as compared to all other years (p-value 0.01). effects of gender were insignificant when related to burnout. the jse-student edition reported mean score per item for our population to be 4.62±0.57, where a maximum score of seven was possible. females (5.56±0.72) had higher empathy scores than their male counterparts (4.46±0.65) according to the independent t-test and this was significant (p-value0.04). anova was employed to see difference of empathy across 5 academic years, this showed no statistical significance.(f=.86, p-value 0.44).the various disciplines of health sciences when compared with empathy showed statistical significance (f=4.66. p-value 0.03) and it was seen that students in medical sciences has a lower empathy score than those in optometry and medical laboratory techniques. anova was administered to see the effects of gender, year of study and discipline of study on empathy. there was a significant difference was found concerning empathy between year of study and discipline (f=0.86,p-value0.01). post hoc tukey’s test showed that 3rd year students had a higher score of empathy as compared to other years (n=166, mean score 5.65±0.75) (table 2) table 3: main themes relating to empathy and the hidden curriculum (n=90) theme/similar statement students reporting this theme n(%) negative/positive role modelling affects empathy 32 ( 35.5 ) sociopolitical scenario of the country affects empathy and patient dealing 49 (54.4) patient behavior affects empathy 59 (65.5) lack of proper incentives in medical field, extreme stress and burnout 49 (54.4) ambience and administration of the institute 36( 40) in the second stage of the study qualitative open-ended questioning was performed by using focus groups. two focused groups comprised of 15 students of mixed disciplines were selected from each of university total 6 groups of all three universities were comprised of 90 students. mentor who was not teaching any of the students was appointed for each focused group to start discussions pertaining to empathy, burnout and the hidden curriculum. themes which emerged more commonly were tabulated and answers of the students recorded.(table 3) discussion our study showed that a high percentage of students suffered from burnout especially students of medical sciences and those is advanced years of their study, this is probably because of the intense pressure and increasing amount of work load on these students and also increased expectations. these results are corroborated by other previous studies, such as a study hidden curriculum & burnout/empathy j aziz fatm med den college january – june 2021; vol. 3, no. 1 11 conducted in medical colleges of lahore showed similar results12, similarly the mbi-ss conducted in a university in israel had similar findings also.15our study reported a much higher rate of burnout syndrome (40%) than most of the reported literature (falling in the ranges of 10-25%),16–19this is most likely as most studies are done in developed countries with a wellstructured support system and medical facilitates and proper defined working hours for residents, as compared to them the healthcare system in pakistan is in infancy, hence there is lack of proper facilities in hospitals as well as lack of proper teaching time and techniques in medical colleges which makes it more likely that our students suffer from higher rates of mental and emotional exhaustion. 12 in current study, the jefferson empathy score determined that there was a bell shaped distribution in empathy curve over the five years of a health science degree program, with a low level of empathy in 1st two years, then a rise in the third year and again low levels in the next two years. this was corroborated by some articles which also stated that empathy levels of medical students declined with senior years.20,21 the rise in third year is likely due to the fact that our clinical training usually starts in third year and most students start this time with much zeal and fervor, these effects die down by the time they reach final year due to various issues such as the influences of hidden curriculum, higher rates of burnout, peer pressure etc.22 in our study a negative relation was seen between empathy and burnout, showing that students, who exhibited higher rates of burnout, had lower empathy scores. this correlation has also previously been established in some studies done in icu residents and nursing professionals.23,24 the qualitative portion of our study showed some novel concept relating empathy and burnout to the hidden curriculum. conventionally, the hidden curriculum is limited to the actions and behavior of the teacher or immediate classroom surrounding that the student takes in subliminally,9 however our study showed that the hidden curriculum is an elusive term and includes a much larger field of things than just behavioral attributes of the teacher. it also includes the type of administration of the institute, the overall ambience of the surroundings, mentorship by teachers as well as seniors. our study showed that most students mimicked the behavior of their teachers as a result of negative or positive role modelling and this was a contributing factor to their rise in empathy or fall there off. this has also been reported to a smaller extent in previous literature.8,21,23 we also found that student empathy was considerably affected by sociopolitical conditions of the country. during times of stress, empathy levels were reported to decline and during times of well-being they rose. a huge factor reported by most students regarding empathy was patient behavior during the ward rotations, those who had negative experiences or rude encounters with patients reported decrease in empathy. limitation: limitation is we did not do in depth interview, which would have generate more data, furthermore we did not take into account cultural and social factors of different institutes and different specialties. conclusion in conclusion, our study showed that burnout is highly prevalent in students of health sciences in particular medical students and it has a negative impact on empathy levels, which are declining in health care professionals with senior students having less empathy as compared to juniors. when we explored the caused, we found that stress and the hidden curriculum were significant players in this problem. where normally we focus more on the academic curriculum, our study reveals that the hidden curriculum and particularly its more unentertained aspects (effects of sociopolitical conditions, administration, and patient behavior) are all very important and crucial for health, wellbeing and empathy of health science students. hence, tending to the hidden curriculum trying to eliminate its negative and highlight its positive aspects is the need of the day to avoid the burnout and empathy in our student population. funding source: none. conflicts of interest: none. acknowledgement we acknowledged all institutes who allowed us to carry out this research. we are also highly grateful to all mentors who helps us in collecting data for this research work. references 1. austin ej, evans p, goldwater 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